About IBD Podcast Episode 118 Cover

About IBD Podcast Episode 118 – Cannabis and IBD

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There are significant unmet needs for IBD patients that include pain control, sleep disturbances, anxiety, and depression. Some patients turn to medical cannabis for these symptoms. But is that a good idea, does it work, and what should patients and their doctors know about medical cannabis? To answer these questions and more, Amber talks to cannabis and IBD expert Dr Jami Kinnucan, who is a Senior Associate Consultant in the Section of Gastroenterology and Hepatology at the Mayo Clinic in Jacksonville, Florida.

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Concepts discussed on this episode:

Find Jami A. Kinnucan, MD at:

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Credits:

Episode transcript and more information at: https:/bit.ly/AIBD118

Related research:

  • Yacyshyn B, Ginsberg DC, Gilder K, et al. Su1930 – Safety and efficacy of olorinab, a peripherally restricted, highly selective, cannabinoid receptor 2 agonist in a phase 2A study in chronic abdominal pain associated with Crohn’s disease. Gastroenterology. 2019;156:S-665. doi:10.1016/S0016-5085(19)38567-1. https://www.gastrojournal.org/article/S0016-5085(19)38567-1/pdf
  • Storr M, Devlin S, Kaplan GG, Panaccione R, Andrews CN. Cannabis use provides symptom relief in patients with inflammatory bowel disease but is associated with worse disease prognosis in patients with Crohn’s disease. Inflamm Bowel Dis. 2014;20(3):472-480. doi:10.1097/01.MIB.0000440982.79036.d6. https://academic.oup.com/ibdjournal/article/20/3/472/4578983?login=false

[Music: IBD Dance Party]

Amber Tresca  0:00 

Hey everybody, its Amber, I want to tell you real quick about the Sherman prize. The Sherman prize is an award created by Bruce and Cynthia Sherman to recognize those who are making great contributions to the field of research and care in inflammatory bowel disease. The Sherman family has been touched by IBD. And their goal is to create a ripple effect that spreads awareness fosters innovation, and provides inspiration in the hope that in the future, other families won’t have to contend with IBD in the way that theirs has.

Amber Tresca  0:29 

Every year. The Sherman prize honors three people who go above and beyond to contribute to the IBD community by generating positive benefits on behalf of patients, their families and caregivers, and the future trajectory of the field. winners received national recognition and a financial prize and a short video highlighting his or her achievements is produced and distributed. Nominees can be IBD, clinicians, surgeons, researchers, or academics who are making exceptional contributions to transforming IBD care.

Amber Tresca  0:59 

What’s more, anyone can make a nomination for the prize this year in 2022. The nominations closed on June 8, so if there’s someone you would like to nominate, go to Sherman prize.org, to learn more, and to submit a nomination once more. That’s Sherman prize.org.

Amber Tresca  1:22 

I’m Amber Tresca. And this is About IBD. It’s my mission to educate people living with Crohn’s disease or ulcerative colitis, about their disease, and to bring awareness to the patient journey.

Amber Tresca  1:32 

Welcome to Episode 118.

Amber Tresca  1:35 

As it is becoming legal for medicinal or recreational use in more places, people with IBD are trying cannabis. And that is not a surprise. There are significant unmet needs for IBD patients that include pain control, sleep disturbances, anxiety, and depression. It stands to reason that people would try cannabis to manage these problems.

Amber Tresca  1:55 

The issue is that we don’t know a lot about how the chemicals in cannabis interact with IBD. There are some studies but nowhere near enough and that’s not for a lack of interest. I myself have shied away from this topic for a long time because there wasn’t much evidence for me to fall back on. And I didn’t know how to help IBD patients understand how to put cannabis into context. However, that is starting to change and cannabis is now a subject that’s being discussed more openly, not just in patient spaces, but also in the physician community as well.

Amber Tresca  2:28 

That’s why I reached out for help from Dr Jami Kinnucan. Dr Kinnucan is a Senior Associate consultant in the Section of Gastroenterology and Hepatology at the Mayo Clinic in Jacksonville, Florida. She also started the Women in GI committee at the University of Michigan, currently serves as the co chair for women in IBD task force for the Crohn’s and Colitis Foundation National Scientific Advisory Committee and is a member of the American College of gastroenterology, women and gastroenterology committee. And after all that, in her spare time, she serves as the medical editor for Self Magazine.

Amber Tresca  3:01 

She’s the right person for this conversation, and you will quickly understand why as she answers our questions about cannabis.

Amber Tresca  3:12 

Dr Kinnucan, thank you so much for coming on about IBD

Dr Jami Kinnucan  3:15 

Thank you, Amber for having me on your podcast.

Amber Tresca  3:18 

We all need to know more about cannabis and IBD. But I want to start with something really basic. Do you think you can give an overview about these terms? We hear cannabis THC, CBD? What are these things?

Dr Jami Kinnucan  3:31 

That’s a great starting point. I’m actually quite excited to chat with you about this topic, mainly to raise awareness and dispel some of the misconceptions and myths that surround cannabis and IBD. Which is much of which I think why you’re excited to talk about this topic today.

Dr Jami Kinnucan  3:45 

Yes, many patients actually come to my clinic hoping that I’m going to tell them that they can stop all their medical therapies and that they should start using cannabis every day. But I don’t even know that patients understand what that might mean. And so I agree, I think the best way to start is there’s all these confusing terms out there, some of which are very hard to pronounce multiple times.

Dr Jami Kinnucan  4:05 

But mainly what we like to think about is we think about cannabis in the form of two main varieties, and they call them strains. But now they’re actually starting to call them chemical varieties. But you may hear strains, if you go to a dispensary, there’s Cannabis sativa and there’s Cannabis indica. So maybe you’ve heard about some of those terms, but the things that you’re asking about are the compounds that are within cannabis. There’s actually hundreds of compounds within cannabis. But the two most common cannabinoids are delta nine tetrahydrocannabinol. I’ll say that 10 times fast. So that’s what we call THC. And then cannabidiol or CBD, and then there’s a bunch of other ones that you may read about or hear about, but these are the two main ones that you’re going to be most familiar with if you’re going to consider using cannabis and what you want to know a little bit more about.

Dr Jami Kinnucan  4:54 

Each of the chemical varieties have different ratios of THC and CBD. One this things that comes up often is what is hemp. So hemp is derived from the cannabis plant, Cannabis sativa. And it’s mainly composed of CBD with very little to no THC so less than point 3%. And hemp is actually federally legal, because in 2018, there was the farm bill that passed the expansion and legalization of hemp, which again, is predominantly CBD. But we know that cannabis in general, when we think about cannabis that contains THC is still considered on a federal level to be a scheduled one substance. Whereas at individual state levels, there are varying degrees of legalization from medicinal use all the way to recreational use in some states.

Amber Tresca  5:44 

So you just told me so many things that I already did not know. And it’s interesting what you were saying about the strains, because I live in Connecticut, where medical cannabis is legal. I think we also just legalized recreational, but I think that’s getting off to a slow start. But when you go, I will disclose that I do have my medical card. But when you go to a dispensary, I hear from people in other states who talk about all of these wild names that they have. But in Connecticut, they have like numbers and letters for the names. So do you think that that’s a trend that’s going to continue as we think of cannabis as a more medical idea than a recreational one?

Dr Jami Kinnucan  6:27 

So it’s really interesting. And so the challenge is, is that you know, every state has their own laws, and then within each dispensary, so it’s not even that every state has one dispensary and each dispensaries have their own company. And they’re all growing their own chemical varieties, which is the new sort of coined term outside of strains, because they’re growing things that are Cannabis sativa only they’re growing things that are Cannabis indica only, and then they’re growing hybrid strains, or hybrid chemical varieties. So you’re gonna see even state to state variations.

Dr Jami Kinnucan  7:00 

And so it’s really I think, if you do have your medical card and you’re working with either a recreational or medicinal dispensary is to ask questions. And the questions that you want to ask is what chemical variety is this? Is this sativa? Is this indica? Is it a hybrid strain? What percent of CBD and THC or how many milligrams are present in each? Is this considered a high dose versus a low dose? So there’s lots of I think, questions that that can hopefully help patients go in with at least more baseline knowledge to ask the right questions, to be able to get some answers. If you’re at a dispensary and they can’t tell you the answers to those things, then I would maybe look into a different dispensary.

Dr Jami Kinnucan  7:42 

So they should be able to give you that information. And they have that information available to them. But again, these are unregulated substances, right. And so at this point, they have to disclose what’s in them. But it could be varying percentages of you know, and mainly, I think the one that we think the most about, in terms of adverse events or adverse effects in the body is THC. And so higher levels of THC can produce higher levels of that psychoactive component of, of how we think about cannabis.

Dr Jami Kinnucan  8:14 

And so I always recommend when patients are considering doing this is to a work with a dispensary and be start at the lowest dose of THC that’s possible, or even considering starting a CBD only brand or chemical variety. And we can talk a little bit more about that and what’s been studied in IBD. But, you know, if you’ve never been exposed to THC, and you don’t know how you’re going to react to it, you certainly don’t want to start off at the highest dosing, which, you know, the average in medical and recreational dispensaries is about 20 to 40% thc. But certainly there’s lots of different chemical varieties that have lower THC in them.

Amber Tresca  8:51 

Right. And that has been my experience so far is that the people of the dispensary are extremely knowledgeable and super happy to answer all the questions. And I also found it really bizarre that it was easier to get a medical card than it is sometimes to get my biologic. So it’s a very weird, weird space.

[MUSIC: About IBD Transition]

Amber Tresca  9:28 

So we don’t have a lot of research. So we really don’t know too much about what can happen between IBD and cannabis. But is there anything that we do know so far?

Dr Jami Kinnucan  9:38 

Yeah. And I think you’re right, that this is a space that has a paucity of data. And a lot of that is due to the fact that the current federal status of cannabis, and I’m not promoting that, you know, we need to legalize this nationally. I think that we need to be able to live our lives the way that we are able to study it so that we can get the data that we need. To help patients, but I am going to sort of generalize some of the studies that we know.

Dr Jami Kinnucan  10:05 

And basically, we have studies that are retrospective reviews. So we take a bunch of patients who have IBD. And they’ve used cannabis. And we asked them, you know how they did. So there’s a little bit of bias in that, right. And then we have some small randomized controlled studies, which I won’t go into detail give you sort of 10,000 foot view of the findings, and then where we need to go and how do we get more information so that we can really answer this question, you know, what do we know? So we know that patients with IBD are using cannabis. And it sounds like Amber you are one of those patients. And we can talk a little bit as to why you’re using cannabis. And I’ll talk a little bit why the it’s important to talk to healthcare providers about using it.

Dr Jami Kinnucan  10:44 

And we know that more patients, especially as the legalization status changes throughout the country and in different states have reported more use of cannabis to relieve IBD symptoms. We also know from studies that patients who use cannabis do not voluntarily report or disclose this to their health care providers with their teams. I asked every patient and I’m sure that there are patients that use cannabis that don’t disclose that on their initial assessment with us.

Dr Jami Kinnucan  11:11 

We know that IBD patients in remission that report cannabis use, and we did this study at Northwestern with Dr. Hanauer showed that patients had higher levels of fecal calprotectin, which is that marker for inflammation than non user. So you take a group of patients who all feel well, and you take patients who are using cannabis for whatever reason, maybe it’s recreationally, maybe it’s for medicinal reasons. And we’ve we measured their stool testing, we see higher levels of fecal calprotectin. This is sort of hypothesis generating studies. We certainly don’t know why that might be. But it may suggest is there a potential negative impact to cannabis? And it certainly raises the question that we need more information.

Dr Jami Kinnucan  11:51 

We also know that IBD patients who use cannabis have an increased risk for surgery. Now this study we have to take with a grain of salt, it was a large study out of Canada. And it basically took patients that were using cannabis and weren’t using cannabis and then and then look to see what their risk for surgery was. If we could speculate that maybe patients who were using cannabis with IBD are more likely to have symptoms, and those symptoms are due to more severe disease, then one could argue using cannabis potentially masks underlying disease and so we’re missing the opportunity to help those patients.

Dr Jami Kinnucan  12:26 

I think that’s what brings up the point is why it’s so important to talk about cannabis use with your healthcare team is because if you’re using cannabis for persistent severe abdominal symptoms, well maybe eyes, your healthcare provider would have some ideas of other things that we could be looking into as to why why are you having abdominal pain? Is there something that’s going wrong with your Crohn’s disease, versus just masking this symptom symptoms with cannabis. The other thing I think that’s even the most important thing, this is the one that I highlight to my own patients.

Dr Jami Kinnucan  12:56 

Patients with with IBD who use cannabis are significantly more likely to stop their medical therapies. And that’s where I think the true risk comes in with patients with inflammatory bowel disease. If you’re taking cannabis and you feel better using cannabis, and you presume that your biologic a isn’t working for you, and you stop it, it may actually be working to treat your Crohn’s. It’s just not working to treat your underlying potential causes to the ongoing symptoms. Maybe it’s decreased appetite, maybe it’s sleep disturbances, maybe it’s persistent abdominal pain, or diarrhea. And we know that cannabis can make those symptoms better.

Amber Tresca  13:33 

So it sounds to me and correct me if I’m wrong. But it’s not really so much about using the cannabis. It’s about the idea that it could be masking symptoms, or that people are using it in instead of a therapy that could actually reduce the inflammation.

Dr Jami Kinnucan  13:51 

Yeah, I mean, I think that you’re thinking about that the right way. And so that we don’t necessarily know that cannabis use in IBD patients is of high risk, I think it’s all the things that surround it. It’s the idea that you’re you aren’t disclosing that your belly pain is actually better. Because you’re using cannabis to your provider who may decide that they would want to do more evaluation if they knew you were having daily abdominal pain requiring cannabis use. It’s about stopping medical therapies that are proven to be effective to treat Crohn’s disease or ulcerative colitis.

Dr Jami Kinnucan  14:21 

To just give context to how has it been studied. What’s the best quality data that we have. So we do have limited randomized controlled studies. So these are the studies that we we look to when we approve medical therapies for inflammatory bowel disease. And so we have a few small randomized controlled studies with Crohn’s disease and ulcerative colitis separated less than 250 patients altogether and all of these studies, and in majority of the studies, patients reported symptom improvement. There was one study where patients actually felt worse and withdrew from the study. But really, I think the most important take home for our audience today is none of these studies showed significant impact and inflammation.

Dr Jami Kinnucan  14:59 

Now it’s not to say You know, why are we even talking about cannabis and CBD? Because there are some preclinical studies studies that have been done in animals that look empty, blocking various parts of the the endocannabinoid system, which is where cannabis acts. And there’s two main receptors. And if we block those directly, in preclinical studies, we do see improvement and inflammation. So I think that there’s some, there’s something to this. It’s just what is the right dose? What is the right chemical variety? What is the right percent THC? What’s the best way to give it? Those are the things that we don’t have the answers to right now.

Amber Tresca  15:33 

Right? We don’t have those answers. I know that it is also difficult to actually get studies done. I mean, it’s one thing to do surveys, but actual studies can be more challenging. And so it’s important for these reasons, while this is all getting sorted out, that patients do disclose, but coming to your doctor and telling them that you’re using a substance that is not legal federally, can be challenging for patients, but their doctors really need to know. So how do you start that conversation? You said that you you do actually ask your patients? So how does that conversation usually go?

Dr Jami Kinnucan  16:12 

Yeah, I mean, I think it’s, you know, not all providers are going to be the same. And there certainly may be providers that are not supportive of patients using cannabis. I think that I take every situation with each patient individually. And we work together to improve your quality of life, and only you, you understand, you know what that high quality of life is for you. And so I think part of the discussion that I start with patients and is just asking, you know, how are you feeling? What are you using every day? Are there any non medical therapies, non prescribed therapies that you’re using to control symptoms.

Dr Jami Kinnucan  16:47 

So if patients say, I feel great, this is the best I’ve ever felt I dig a little bit deeper. And not because I suspected they’re using because I want to make sure that they feel open to having that conversation. Oftentimes, in an initial visit, I’ll ask about different substance use. So it’s important that we understand about smoking history, especially in patients with ulcerative colitis. And Crohn’s. It’s important that we have a conversation around alcohol use, especially when it impacts the liver. But also we know that excessive alcohol use can impact patients symptoms and experience with IBD.

Dr Jami Kinnucan  17:18 

And then I say, and there is some data that cannabis may help improve symptoms, are you have you ever tried cannabis? Or used cannabis for your disease? And then if patients say yes, I follow up with, tell me about your experience with it? How are you using it? What formulations were you using? Because I’m trying to learn to about what my patients are using and what’s benefiting them. So I think that the more open we are as providers when that information is disclosed, I certainly come at it from a place where I understand that there is value in adding cannabis.

Dr Jami Kinnucan  17:49 

So I disclosed that that there are some patients that benefit from the use of cannabis. Have you tried it? And are you one of those patients that has tried using cannabis? Are you currently using cannabis, it’s it’s important that we understand that because it’s important that we we incorporate that as part of your treatment plan. So I think that it’s the way it’s how it’s phrased.

Dr Jami Kinnucan  18:06 

So maybe this is more of a podcast that we should give to providers, so that they’re helping patients feel more comfortable. You know, talking about this, I think you’re right, that one of the reasons is because it’s federally illegal patients feel like there might be as a stigma that’s attached to that. Maybe they don’t feel like their providers will be supportive of them using it. And I think that a lot of the things that I’ve heard when patients see me is that they’ve never talked about it because when they have their providers seem to have no knowledge of cannabis, or how cannabis could be beneficial or even discuss any potential risks of using cannabis with them.

[MUSIC: About IBD Transition]

Amber Tresca  19:01 

Alright, so we don’t know a lot. We’re kind of flying a little bit blind here. But patients are using it. And they’re using it for things like pain or sleep. We already talked about how they can ask the folks at the dispensary. Who are, it’s been my experience that they are extremely knowledgeable. So where else can they learn? Where else can patients look to get some information?

Dr Jami Kinnucan  19:26 

You’re asking something that’s incredibly important and something we actually recently looked into ourselves. So we presented data and we’re going to be publishing this data hopefully this summer. We looked at dispensary use in IBD patients from a New York dispensary. So singular data from a single dispensary and this is for medicinal use only. So patients had to be certified by a provider as having Crohn’s disease or ulcerative colitis and another symptom so they couldn’t just have a diagnosis of IBD in the state of New York at the time of our study, to look at this so we look retrospectively at the database To see what are patients taking what formulations, what percent THC, how much CBD.

Dr Jami Kinnucan  20:05 

And what we found in this study is that the amount that’s being given or recommended by a medicinal dispensary was significantly lower than the dosing that we’re seeing that studied in the small randomized controlled trials. There’s even a disconnect there, right? And so we’re seeing benefit in these randomized controlled trials in patients symptoms, least some of them. But some, some of the studies actually didn’t show any benefit. But then we’re not even using the dosing or recommending the dosing for patients that we’re seeing that benefit. So yeah, there has to be me, you know, the truth is, is that we don’t have any guidance, and the dispensaries don’t necessarily have good high quality data to tell patients.

Dr Jami Kinnucan  20:47 

So where do we start? And what do I tell patients? So first, I prefer a non inhalation form of cannabis for patients. Just because we know that there’s risks with inhalation. However, we know that inhalation forms of cannabis. So smoking cannabis gives you the most immediate impact because of its onset of action. So for some patients who are using it for pain, that’s where we’re going to get the quickest onset of action. But again, if we’re going to have chronic use of this particular therapy as adjuvant to our medicinal for our medical therapies. This is where I would prefer an oral or a tincture formulation for a patient.

Dr Jami Kinnucan  21:23 

Then I have them look at combination chemical variety, so CBD with THC. And as I spoke before, especially in THC, naive patients, I have them start at the lowest dose of THC to see how they react or what their experience is with that particular agent. Some patients like to start with CBD alone, but many of the patients that start with CBD alone don’t seem to notice as much benefit. And maybe it’s because the CBD dosing that they’re using is, again, less than what’s been studied in the trials. But in the studies that were done in IBD patients, those that looked at CBD alone, really had no benefit.

Dr Jami Kinnucan  21:59 

So I don’t think that CBD is where it’s at. I think it’s about a synergistic effect between the two main cannabinoids and how they impact patients symptoms. So I think it’s a done, it’s a personalized individual experience of titration. And I would love to hear your experience of how you introduced cannabinoids, if you feel comfortable talking about it, and how you sort of found your way within the within the process.

Amber Tresca  22:22  

Yeah, and I would say that I I’m not really sure that I found my way to be honest, I was interested in getting better sleep, which has been an ongoing problem. And so we thought we would just try it, and it has not produced the kind of results that kind of make it worthwhile, I guess is what I would say about that. So and I’ve heard from other patients that are like, this finally gave me the best sleep of my life or you know, whatever.

Amber Tresca  22:50 

But it hasn’t been that at all, you know, and in your talking about CBD, I have found that adding CBD was more helpful. However, CBD, it’s my understanding that it’s not regulated at all. So what’s in it is, you know, kind of like a toss up. So it’s depending on what you’re getting and what it is. And honestly, it’s so tricky to me. I mean, I’m not a chemist, you know. And that’s what I feel like sometimes is that you almost, you know, you need somebody with some background in chemistry to really direct you.

Amber Tresca  23:25 

And there’s not really anyone that can tell you definitively. So you are experimenting a little bit in your own body, which as IBD patients, we unfortunately are sort of used to, but also you know, I mean, I have children, I have a life I don’t know, I don’t have days and days to mess around with this and just like figure out what’s going on. So it hasn’t been any kind of a, you know, great big solution for me.

Amber Tresca  23:55 

And like you were talking, I do also worry about the potential harms. And I stuck with the edibles. And in Connecticut, they have some they have some funny things about edibles, you can only get certain ones like you can’t get a gummy, but you can get a cookie. I don’t know it’s a little odd. But that’s how it has gone here in this state. And that’s the other thing is that every state does things differently. So it’s hard to generalize.

Dr Jami Kinnucan  24:18 

Yeah, you’re I mean, I think that we I mean you’re like hitting the nail on the head. This is the experience that we have as providers on our site because I want to be able to have information and have data and have something to guide patients. We know that out of the two chemical varieties of cannabis indica seems to have a higher level of CBD and have a more calming effect. And so patients and it’s often thought of as like the sleep of potentially cannabinoid or cannabinoids

Amber Tresca  24:45 

…and that’s what I was recommended to use…

Dr Jami Kinnucan  24:48 

And you’re right. There’s various forms and percentages of CBD that’s present in that plus additional things that are that you may not have a positive reaction to some patients To actually have a very sedating effect with THC. And some patients have a stimulating effect. So again, that’s sort of that experiment, and we don’t necessarily know how you’re going to respond.

Dr Jami Kinnucan  25:09 

You know, interestingly, I worked with one of our sleep experts at the University of Michigan, who’s a good friend of mine, Dr. Cathy Goldstein. And she actually raised my awareness because a lot of my patients if they weren’t using it for pain, were using cannabinoids for sleep. And, and when asked me, you know, do I have any concerns about this? And so, you know, I really looked at her as somebody who’s a sleep expert, you know, what, what should I be concerned about.

Dr Jami Kinnucan  25:29 

And so what she, what she pointed out in some of the studies that had been done in there a couple years old is that patients who were using chronic cannabinoids for sleep, they started to see that they were requiring higher levels of the same cannabinoids to be able to get the same level of sleep improvement. However, they did see when they studied low doses of cannabinoids, it very objectively, not just saying like, hey, ever How’d you sleep? They actually objectively studied this and they saw improvement in sleep parameters.

Dr Jami Kinnucan  25:56 

So there is there is objective data to support that, that there there is an impact of using Lodos cannabinoids. So the question is, is what dose what formulation? How should you be using it. But the thing that she raised to me that I bring up with patients is, when you use it more than five times a week, it can actually lead to increased sleep disturbances that are measured. And then patients who use it chronically and at high doses can actually have cannabis withdrawal symptoms. And that can actually lead to sleep disturbances for up to a month, month and a half. So there are impacts that can linger. And these, again, are based on small numbers. But there is some information out there and at least you know, from a sleep expert, it’s not as you know, as easy as just taking something and saying oh, it’s improving my sleep actually can have impact on your sleep quality moving forward.

Amber Tresca  26:42 

Right. So this this is the type of things that I want patients to understand is that it’s not as easy as going and getting your card and then going to the dispensary and having a conver… like A conversation. And then it ends there, like it is an ongoing thing. It’s an ongoing discussion. And you also need to be aware of the potential effects, the beneficial ones, but also the adverse effects.

[MUSIC: About IBD Transition]

Amber Tresca  27:12 

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Amber Tresca  27:40 

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Amber Tresca  28:12 

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Amber Tresca  28:42 

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[MUSIC: About IBD Transition]

Amber Tresca  29:02 

So you talked about sleep, but there could be other adverse effects. And I’m seeing just sort of anecdotally like on Twitter that some of the gastroenterologist have been talking about some of them. So I wonder if you wouldn’t mind discussing that a little bit.

Dr Jami Kinnucan  29:16 

Yeah, absolutely. So just to point out I mean, there are so many other both pharmacologic agents as well as we have a lot of benefit in our patient population of working with a sleep psychologist who is actually in a really incredible important person in a sleep practice. If you’re having a lot of issues with sleep disturbances, and this is actually something that I had studied previously, we know that that potentially can impact your inflammatory bowel disease and your disease activity. So seeking assistance for sleep related concerns and not necessarily saying I’m going to go to cannabis I think is important.

Dr Jami Kinnucan  29:49 

Many people use it as a last resort. I have tried everything. It’s not working. I’m going to use cannabis but there are lots of other options out there. And if your gastroenterologist knows that sleep psychologist They’re an actual an excellent partner and the team. But you’re right, you’re raising questions about the risks, and how do we counsel patients about risks? So, you know, everything has risk, right? Any of the medicines that we prescribe for IBD patients, they have risk and so everything has to be talked about, and how do we weigh the risks against the the benefits, and we can’t take a one size fits all approach.

Dr Jami Kinnucan  30:22 

So a few things that I counsel my patients on that want to come in using cannabis as adjuvant therapy, not saying doctor, you’re gonna want to replace all of my medicines with cannabis is I talked about the risk for drug interactions. So people don’t know this, but both THC and CBD are actually very potent interactors. So one is an inhibitor and one is a stimulant of the SIP CYP enzyme system in the liver, which is how our bodies process many medications.

Dr Jami Kinnucan  30:48 

And these are medications like blood thinners like Coumadin and warfarin, which are very important. We don’t want to mess with that. Alcohol, which is why cannabis and alcohol together have exacerbating effects. Epilepsy medications, of course, are really important and some other other medications, as well. So it’s important that if you are going to introduce higher doses of cannabinoids into your body, that you that you work with a pharmacist if they have one at your dispensary, or your own pharmacist who’s managing the other medications, to make sure that there aren’t any big interactions that you need to be worried about that would either increase or decrease the effectiveness of the other treatments that you’re on.

Dr Jami Kinnucan  31:23 

We know that chronic use has been associated with cannabis hyperemesis syndrome, which is probably what you’re speaking to and what you’ve seen on Twitter. This was something that was that wasn’t really given a name for a long time and now is officially part of the Rome four criteria. And essentially, these are patients that use chronic daily cannabis who come in with pretty significant profound cyclical vomiting, and getting dehydrated require hospitalization, it’s a pretty significant, intense clinical presentation. And the good news is, is it’s treatable, because just stopping cannabis is actually how we treat cannabis hyperemesis syndrome, patients can get very sick and be misdiagnosed for a long time, unless it’s recognized that this is what this says, in younger patients, there’s been associations with a decrease in IQ measured IQ as well as increased risk for mental health disorders.

Dr Jami Kinnucan  32:12 

We know patients with IBD are more likely than the general population to have comorbid, anxiety and depression. And so if you add on cannabinoid use on top of undertreated or underrecognized, anxiety and depression, we can potentially see some worsening of those potential disorders. And then they looked at different impacts in cardiovascular health, there’s some literature about increasing blood pressure, potentially an increase for a read me as lung health with smoking and inhaling substances. It’s not like you’re just inhaling a pure substance, there’s potential that there’s other chemicals and carcinogens in there. Of course, there’s risks surrounding pregnancy. And then there’s obviously addiction potential that’s been raised, you know, quote, cannabis is the gateway drug.

Dr Jami Kinnucan  32:52 

But, but more of that, you know, addiction is the dependence on a substance. And so it doesn’t matter whether it’s on cannabis or something else. And then of course, driving impairment, and what that may look like, the studies continued to be done looking at risk.

Dr Jami Kinnucan  33:06 

These risks are something that to note, certainly, if there’s benefit in using cannabis for a particular patient, we talked about these risks, but we talked about that most of the medicines that we prescribe also have risk. And so we just weigh those risks and benefits for them.

Amber Tresca  33:20 

I think, in some ways, for for myself, or maybe people the same age as me growing up in the 80s, this idea that cannabis is a drug, and until recently was illegal to use for any purpose, and therefore is something that you should be hiding its use or, you know, there has stigma associated with it, you should be ashamed of of using it. So I think for myself, that’s a little bit in there, that we’re teaching people kind of when they’re young, about the risks, it’s not taking a whole picture, look at the substance, and how it could potentially be used for beneficial purposes, if we just know what we’re doing. But it unfortunately, sounds like we don’t quite know what we’re what we’re doing.

Dr Jami Kinnucan  34:11 

Yes. Yeah, it does kind of feel a little bit like we’ve put the cart before the horse and where I think that we’re going to find and there there are large cannabis related or, you know, nonprofit organizations that one of which I presented at their conference, the Cannabis Research Foundation, that are invested in figuring this out. They’re invested in finding the answers not promoting cannabis, but finding the answers of where can there be therapeutic benefit. And how can we be using this?

Dr Jami Kinnucan  34:39 

You know, and then there’s patients that are using it recreationally, right, like just like they’re drinking alcohol, they’re using it because they enjoy using cannabis and that’s different. I think what we’re talking about is where do we see this medical impact?

Dr Jami Kinnucan  34:51 

Peter Higgins, who I was working with at at Michigan Medicine, prior to coming to the Mayo Clinic, and some colleagues did did a study Looking at actually targeting the receptor. So I think that there’s no doubt in my mind and many people’s minds that study cannabis is that the Endocannabinoid receptor system is a very prime target, potentially in the anti inflammatory pain, mood pathway. These receptors exist in the gut there exist on lymph tissue, they exist in the brain, there’s very clear endocannabinoids cannabinoids that are that our body makes, and what those impacts of upregulation and downregulation do to the body?

Dr Jami Kinnucan  35:36 

The question is, do we have we found this natural form that is able to interact with these receptors? And is there impact and is there benefit? You know, Dr. Higgins and and some colleagues really looked at well, why don’t we just target the receptor, instead of you know, taking, you know, smoking or taking an animal that has multiple formulations and multiple cannabinoids that aren’t necessarily primarily targeting a receptor? Why don’t we target the receptor and see what happens. And so they did this mainly looking, and it was a CB2 receptor. And CB2 is more prominent for pain regulation. And so when they targeted this, they found that patients felt better, they had less days of pain. And and this is just sort of a very high level overview of that particular study.

Dr Jami Kinnucan  36:21 

But there is definitely, you know, something here, I just don’t think that we’re going out at the right way. I think that we’re, you know, throwing cannabis at it and saying, Well, let’s see what happens. But maybe really what we should be doing is looking at companies that are developing clear targets of these receptors, and seeing how that regulates inflammation and how that regulates symptoms and pain and sleep and all of the all of the the unmet needs for our IBD patients. Right?

Dr Jami Kinnucan  36:47 

No one’s seeking cannabis, because they’re feeling great. They’re seeking out cannabis, right? Because because they’re not feeling well, you know, despite being on medication A or biologic B, they haven’t, they’re not meeting, you know, the quality of life metrics that they’re hoping for, they’re still having pain, they’re not able to eat, they’re nauseous, they’re vomiting, they’re having diarrhea that’s limiting their quality of life, they’re not sleeping well, which then if you don’t sleep, well, it impacts your entire, you know, day.

Dr Jami Kinnucan  37:13 

So they’re, they’re seeking alternative treatments to improve their quality of life. And I think that we as an IBD community, need to recognize the importance of that, as we’re still, while our medicines have are doing a great job and controlling inflammation, and we’re getting better and better at the medications that are coming out and approved by the FDA, we’re still not meeting all the needs of our patients.

Amber Tresca  37:34 

I think the stigma associated with all of this has really set us back. And there’s so much more work going on in this space than I even realized. So I really appreciate you bringing some of it forward. The studies that you’re working on…

Dr Jami Kinnucan  37:47 

I think one of the studies that you’re that we’re that we’re hoping to do. And we’re going to try to partner with Dr Long at UNC and IBD Partners database, because we need we need data like large data, right, because everyone’s doing this. And so in her big database, you know, there’s a subset of patients that are using cannabinoids. But what has never been asked if patients that’s what keeps being asked is are you using Why are you using right? But what’s not being asked?

Dr Jami Kinnucan  38:12 

So what we asked him the dispensary, but I want to ask him the real world what are people using in various states throughout the country? As what are you using? Are you using CBD predominant? Are you using THC predominant? Are you using a mixed stream? or chemical variety? What dose? How many milligrams are you using?

Dr Jami Kinnucan  38:31 

Because that’s where we’re gonna have we’re starting to get data of like, you’re saying like, what should I use? Like, give me a milligram right? You know, you go to the store and you say like, okay, you know, I can take 500 milligrams of Tylenol, I can’t even tell you, because the studies that we have in the randomized controlled fashion, the formulations are all over the place. The dosing is all over the place. And so I can’t even give you you know, a range because it’s so broad.

Dr Jami Kinnucan  38:56 

And then when we look at the real world data, it makes it even more broad. The highest dose in a patient isn’t even the lowest dose that’s been studied in the randomized controlled trial. So then, then I’m looking at randomized data and then I’m looking at real world data and when patients are using it, I actually my hypothesis is that patients in the community because dispensaries don’t know they’re being under dosed. They’re they’re not being given the doses that may potentially have therapeutic benefit. And that doesn’t mean just THC that actually goes for CBD too — CBD as well instead of CBD number two, but that, you know, that goes for CBD as well as that I think that we’re just we don’t know.

Dr Jami Kinnucan  39:35 

And so it’s just sort of like throwing stuff at the wall, seeing what sticks. And I don’t know that that’s really doing what’s right by patients either. I’m glad that patients have more liberalized access to cannabinoids, especially my patients that have had significant improvement in their quality of life and they have found the right formulation and the right dose that has improved their experience with their disease.

Dr Jami Kinnucan  39:57 

And so I’m very grateful that there is that opportunity for patients. But then you’re right, there are patients like yourself where there is no guidance, and your experience hasn’t been as positive and you were seeking benefit, and it wasn’t there. And so, you know, how do we help guide you? And so I have just as many frustrations with you, not with you, but about the experience that you had, as you do. Because, you know, at the end of the day, you’re still not sleeping well.

[MUSIC: About IBD Transition]

Amber Tresca  40:44 

And I wonder, too, about about the smoking because with an edible, you know, what is it? Or at least, you know, what is on the label, I guess, is what I should say. So you should know what you’re receiving as long as that’s all been done properly. But with inhalation, do you know how much you’re getting? Like, that’s something that worries me too.

Dr Jami Kinnucan  41:05 

I mean, you don’t and right, and every body is different. And our, you know, we measure biologic levels, we measure some of our oral therapy levels. But Is anyone out there measuring? You know? Pharmacokinetics in patients who are either using orals or inhalation? We don’t know. And again, it’s what is what is whatever you’re using potentially mixed with? Are you using, you know, bud? Or are you using some sort of oil that potentially could have carcinogens or some other substance that you may have an adverse event to?

Dr Jami Kinnucan  41:39 

So, you know, I mean, I think that the cannabis industry is an incredible industry, and how much money they’re making for various states, right, and states are getting impacted in a very positive way, from a financial standpoint, patients are benefiting by being able to have access. But I do agree that I feel that we don’t have all the guidance in the medical community. And I would say that, you know, these companies ramped up fast, but I they should put their money, where their mouth is, and really invest in research.

Dr Jami Kinnucan  42:10 

And I have said that to a couple of dispensaries, who’ve approached, you know, me about, you know, partnering and researching, but not just research and benefiting their strain, right, or their chemical variety, but research benefiting the cannabis community, and so that we can get the answers so that we can help guide patients. And the answer may be that cannabinoids are not the right answer for IBD. Patients that in any formulation, using cannabinoids just really aren’t going to treat inflammation, they’re not going to make inflammation better. But patients, some patients may feel better. And so it’s going to be patient dependent.

Dr Jami Kinnucan  42:43 

But I really think that we’re where the science is gonna go is direct inhibition of the cannabinoid receptors and seeing therapies and molecules develop that will directly inhibit that that are using cannabis in the current form. That’s where I really see the benefit from a medical standpoint. But I just we’re not there yet. I do have a chemistry friend, I should ask her to develop a molecule for us Amber we could we can we can make a personalized molecule for you.

Amber Tresca  43:12 

You know, what all of all of the folks that that? You know, you’re so plugged into the community, like, can you just Yeah, can you create a dream team like for me, like other people to like, whatever they do, whatever. But just for me, like, can you just get everybody together?

Dr Jami Kinnucan  43:27 

I’m  on it, you just let me know, I will, I will help you.

Amber Tresca  43:31 

I would be a much more pleasant person if I could sleep better. So you’ve given me so much information. I really appreciate it. I shied away from this topic for a very long time, because I just didn’t know what to do with it. I just felt like there wasn’t much to say. But there’s more research being done. People are presenting on IT people like you. I’ve seen some other presentations from some gastroenterologists. And so that has been wonderful to see that we’re talking about this. And so you’re asking your patients and patients are disclosing. And so that’s a really great thing. But I want to know from you, what do you think, is really the most important thing, if you had to distill this all down? The one thing you want patients to come away with about medical cannabis.

Dr Jami Kinnucan  44:19 

Oh, gosh, Amber, you have questions? Well, I want to first thank you for having me. And I also want to say I’m glad that you’re raising awareness to this and you’re so open to share your experience. Because you’re right, not a lot of people are and even though I’ve been talking about this for the last five plus years, ish, maybe a little bit more. There still, there’s not a lot of other people talking about it and two very important things. So the best to our knowledge at most up to date information, Crohn’s and Colitis Foundation. I was on the paper Dr. David Rubin. I’m Dr Arun Swaminath, always I totally butchered his last name. Hopefully you’re not listening to this Arun…

Amber Tresca  45:04 

No, hopefully he is listening to it…

Dr Jami Kinnucan  45:07 

…but I am sorry for butchering your name. No, we did a white paper with the Crohn’s and Colitis Foundation. And we put together all the available evidence. And we had a position statement that we’re calling on the ability to be able to better study, it’s for IBD patients. So if IBD patients want an easy reading, you know, it’s a couple years old now, but we’re most of the up to date information as look at the Crohn’s and Colitis Foundation cannabis, white paper, it’s publicly available. So that would be a really great reading resource to start and, and would really go into more detail than what I did today.

Dr Jami Kinnucan  45:38 

But the most important thing that I can think to tell patients to take home is if you feel that there are symptoms that you’re having, that you would like to explore using cannabinoids, in your medical treatment, partner with your healthcare team, talk about those symptoms with your health care team, especially the ones that are impacting your quality of life.

Dr Jami Kinnucan  46:00 

The number one question I asked at the start of my visit is what are the top three priorities that you have today to discuss? If you’re not doing well? What are the things that we can improve? And so if one of those things is sleep, or pain, or diarrhea, whatever that might be, your healthcare team should evaluate those symptoms further if they haven’t, is your IBD active? And if it is active, could we also benefit by optimizing your medical therapy, in addition to adding adjuvant cannabis, right, but it shouldn’t just be let’s add cannabis and see what happens because we potentially are missing the opportunity to really change your disease by optimizing your medical therapy. So the number one thing is talk to your healthcare provider, let them know about the symptoms that are still impacting your quality of life that are making you want to seek out cannabis into your medical regimen.

Dr Jami Kinnucan  46:47 

And then have that open discussion with them. Push the envelope make them uncomfortable to talk to you about it, because that’s really how we’re going to change the conversation is by you talking about it. And you’re going to go in because you’ve read the white paper and you’re going to know so much about cannabinoids and what’s been studied and what the data shows that you might be able to educate your provider that maybe doesn’t know a lot about it.

Amber Tresca  47:07 

I think we should all go into our providers and say Dr. Kinnucan says I should make you uncomfortable. So here we go…

Dr Jami Kinnucan  47:15 

Oh, man, I’m going to regret saying that. I had too much coffee this morning, Amber, that’s the problem.

[MUSIC: IBD Dance Party]

Amber Tresca  47:20 

I love that. Thank you so much for this conversation. Thank you truly for everything that you’re doing for patients, it is very much appreciated. Sometimes we feel alone. And so knowing that you all are out there, doing the research looking into these things, and the way that you are helping your own patients on an individual basis. And then by coming on my show, you’re helping all of the patients who can listen to this, as well as the providers. So thank you so much for talking with me. I really appreciate your time. We had a little bit of scheduling, and then some technical stuff. And you have just been amazing through all of that. So thank you so much.

Dr Jami Kinnucan  47:58 

Yeah, we figured it out. So the trusty old iPhone works for a podcast.

Amber Tresca  48:05 

Thank you.

Dr Jami Kinnucan  48:05 

All right, so it was nice to see you Amber.

Amber Tresca  48:13 

Hey, super listener. If there’s one takeaway that I want you to have from this episode, it’s that patients and providers need to talk about cannabis use for IBD. Look, I know it’s a tricky subject. And that’s why people don’t disclose. The key here is for providers to create a safe space for their patients, so that there’s comfort and security. In discussing this. Dr. Kinnucan and her colleagues have laid that groundwork and so it’s time to start learning more and listening to why patients are looking to cannabis to ameliorate their symptoms.

Amber Tresca  48:44 

I can’t thank Dr Jami Kinnucan enough, she enthusiastically agreed to tackle this topic with me and I knew she was the right person. Because she has done so much work in this space already. This might be the first time you’re hearing her name or are hearing from her, but it will not be the last. She is a tireless advocate for the IBD community in so many ways. And I encourage you to look at the show notes where I’ve put much more information about her work.

Amber Tresca  49:10 

Links to a written transcript, everyone’s social media handles and more information on the topics we discussed is in the show notes and on my episode 118 page on about ibd.com As always, you can follow me Amber Tresca across all social media as About IBD.

Amber Tresca  49:27 

Thanks for listening and remember until next time, I want you to know more about IBD.

About IBD is a production of Mal and Tal Enterprises.

It is written, produced, and directed by me, Amber Tresca.

Mix and sound design is by Mac Cooney.

Theme music is from Cooney Studio. 

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