IBD Drive Time: Jami Kinnucan, MD, on Using Cannabis in IBD
Jami Kinnucan, MD, reviews the facts and fallacies about the use of cannabis for the treatment of inflammatory bowel disease, and how to discuss the issue with patients, with IBD Drive Time hosts Raymond Cross, MD, and Millie Long, MD.
Jami Kinnucan, MD, is a Senior Associate Consultant in the Section of Gastroenterology and Hepatology at the Mayo Clinic in Jacksonville, Florida. Raymond Cross, MD, is director of the IBD Center at Mercy Medical Center in Baltimore, Maryland, and professor of medicine at the University of Maryland. Millie Long, MD, is a professor of medicine, vice chief of education, and director of the fellowship program in the Division of Gastroenterology and Hepatology at the University of North Carolina at Chapel Hill.
TRANSCRIPT:
Welcome everyone to IBD Drive Time. I'm Raymond Cross from Mercy Medical Center in Baltimore, and I am thrilled to have my friend Jami Kinnucan from Mayo Clinic in Jacksonville here today to talk about marijuana and IBD. This is gonna be a very popular topic. Jami, welcome to IBD Drive Time.
Dr Kinnucan:
Hey, thanks, Ray. Very excited to be here.
Dr Cross:
So, in general, how prevalent? So there's many states now that have legalized cannabis, including Maryland. So when I drive home, I can often smell weed coming through the filters in my truck, even with the windows up. So it's very, very prevalent. But in our patients with IBD, how prevalent is cannabis use, whether it's medical or recreational?
Dr Kinnucan:
Yeah. We don't have that problem in Florida. So it still remains illegal, at least for a recreational use in the state of Florida. But there are medicinal laws, and of course, as you know, the, the landscape among legalization throughout the country is changing, and so likely the use or at what we've seen in the studies is also changing. So one study actually showed that with legalization, there was a doubling of use within IBD patients and, and actually more for recreational use than medicinal use. But the studies kind of vary based on where you're looking. So in Australia and Canada and US, there's various rates, but anywhere from about 10% to as high as 40%, and that includes those that report past use and maybe not current use. So it's, it's more common than I think we think.
Dr Kinnucan:
And part of that is because our patients don't always disclose that they're using either because of legalization status in the state or perceived judgment from their healthcare team. So many patients don't disclose at least openly and sometimes don't disclose when asked. But I think the biggest issue is we as healthcare team members aren't always asking, we're not starting that conversation with our patients. And so it's not a hundred percent their fault. And when we ask about medical therapies, most people don't think of cannabis as a medical therapy. Right? And so they're not going to necessarily be typing that in on their you know, what other medicines are you taking prior to their visit.
Dr Cross:
Yeah. My sense, and I, I haven't looked at this specifically, my sense in the late teens to early thirties that cannabis use is much, much more prevalent than in the older populations. But even in patients that are older, there's still some use. And I ask it routinely for every patient, and I make sure that I let them know that there's no judgment, that it's legal in my state, and I'm just asking, and then I'll ask them about illicit drugs, other illicit drugs. But unfortunately, the way our epic is set up, it still looks like marijuana is an illicit drug, which it's not. So coming back for treatment, you mentioned they don't think about it as a treatment for their IBD. Is there any evidence that cannabis can be used to treat IBD and then the follow up to that is treat symptoms, but treat inflammation?
Dr Kinnucan:
Yeah, that's so I think that there are patients out there that believe that cannabis can be a medical therapy for their IBD, but I don't think they traditionally think about it when we're kind of asking them like, you know, what medicines are you taking? In short, you know, great question, Ray. In short, the answer is no. That in with evidence that we have to date that cannabis in the current form, and I'm, I'll say that and then kind of give that maybe a caveat to that later, is not a treatment for inflammation associated with inflammatory bowel disease. However, patients who are using cannabis, both in sort of retrospective studies, when we ask patients, you know, if they're using cannabis and, and does that improve symptoms, of course there might be a little bit of bias there, right? If you use cannabis, you're more likely to report that it's helpful.
And then in a few randomized controlled studies of ulcerative colitis and Crohn's disease, we have less than 200 patients in randomized controlled studies. So the data is based on very small numbers. Patients report that they have improvement in their symptoms, improved diarrhea, improvement in abdominal pain, they have improved nausea, they have improved vomiting, their appetite gets better. And even some of those studies show that patients feel that their quality of life improves. So if you were to, if your health care team ever came to you and said, Hey, I have something that you can take that is going to improve all of those things, plus improve your quality of life, most patients would sign up, right? The randomized studies that have been done that had shown improvement in symptoms do not meet the endpoint. So what are those endpoints?
It does not meet clinical remission endpoints. So patients, while they feel better, they're not necessarily completely absolving the symptoms that are associated with inflammatory bowel disease. In addition, when we look at biomarkers, because we know that symptoms alone don't define whether or not inflammation is better. Biomarkers of CRP, improving hemoglobin, fecal calprotectin, those also don't seem to improve based on the randomized controlled studies.
And then lastly is, does endoscopy improve when we stick a scope in? Does the colon look better? And it doesn't meet the endpoints of endoscopic remission. So while patients feel better, and that's an important endpoint, I don't want to discount that we don't see necessarily the changes from the inflammation. So then the next question that often gets asked by a patient saying, well, I mean, how can I feel so well with using cannabis, but you're telling me it's not treating my IBD, right?
Dr Kinnucan:
And so outside of the pineal gland, which is obviously in the brain, the largest concentration of endocannabinoid receptors, which is where cannabis is acting, is actually within the gut—anywhere, all the way from the esophagus down to the bottom. And so if you target those receptors and cannabis has a loose targeting of those receptors, you're going to see improvement. It slows down motility, patients have less diarrhea, it improves compliance in the colon. So when the colon is able to get more distended, either with gas or stool, patients experience, potentially, less pain; it decreases, you know, motility in the stomach. So one would say, well, wouldn't patients be more prone to nausea? That nausea impacts seems more centrally mediated in terms of where things are acting within the brain. And so we get improvement in nausea there. But if you have improved nausea, your appetite kind of goes along with that.
And we know both the munchies that patients who use chronic cannabis get can obviously be associated with a positive impact if patients have low appetite. So in short, in humans, patients feel better. Not all patients, but many patients report feeling better. We don't see changes in inflammation in animals is a little bit different, but none of the animals are smoking cannabis. They're actually getting cannabinoid receptor agonists. So we're targeting those receptors a little bit better. And so in animal models, we can see improvement in inflammation and at least those colitis models that we're so used to understanding with other therapeutics. But that has not translated, at least in human studies at this point.
Dr Cross:
We're going to come back to formulations and how you and I position this in our practice. But I just wanted to make a comment that it seems like over the last maybe 10 to 12 years that there's been a shift from patients of mine that seek complementary and alternative treatments using cannabis as a treatment specifically for their disease. And more of this is an adjunctive to make me feel better. I recognize it's not going to make my Crohn's better, but it makes me feel better while we're trying to get things under control. And I don't know if that's coincided as much with medical marijuana legalization or that we have more and more advanced therapies and more options for patients. But I don't know if you've seen that shift, but I have less patients come to me saying they're convinced that cannabis is going to cure their Crohn's and more people using it just for symptom relief. Have you seen the same thing, Jami?
Dr Kinnucan:
Yeah, I think when I think back to, you know, about 10 years ago, and you know, I lived in Michigan at that point, and so I've been through kind of a state that had no laws, that had medicinal laws that went fully recreational. And now living in a state that just has medicinal laws, you know, I sort of saw that shift, I think when things went recreational in Michigan. And as you're experiencing as well is, you know, it's more accessible, right? And so that you don't need certification medically to get it. And so when it's more accessible and it's not necessarily tied to a medical indication, then potentially patients might be thinking about it a little bit differently. But I still kind of see a split when I push patients a little bit. You know, many are using it as an adjuvant therapy and, and recognize that they tried the monotherapy with cannabis. They tried to do cannabis alone, and that didn't result in any meaningful benefit from a disease standpoint. So they've already kind of done their own experiment, but they noticed that they felt better. And so they want to continue that, but now they're open to taking more effective, you know, therapies for their ulcerative colitis or their Crohn's disease. But then I also have still a camp of patients that want to be more natural and how they approach their treatment and are looking really only to use complementary-based therapies. And I have to remind them that the studies that have looked at complementary therapies have looked at them as in complement, right? And adjuvant not as opposed to taking standard or FDA-approved therapies. But I think as providers, the best thing that we can do is just be open and have that conversation and have a treat to target strategy no matter what therapy the patient chooses, right?
If they decide that they just want to take vitamin D to treat their ulcerative colitis, show me that it works. I'll give you, you know, 6 to 8 weeks, let's show that you don't have progression of your disease, because oftentimes they're not going to feel better, and then they'll be coming back to get more effective treatments. But I've been surprised in some patients who have used more complementary therapies, less studied, not a lot of evidence that I've shown have really surprised me in terms of what their inflammation burden has done. But, you know, an N of 1 doesn't equal you know, a well done study to be able to start recommending that broadly to patients.
Dr Cross:
And I, yeah, I think no matter what you do, you're still doing a treat to target approach pairing symptoms with something objective, a biomarker and eventually scope imaging, something like that.
I wanted to talk a little bit about comorbid conditions and extraintestinal manifestations. And we recognize that extraintestinal manifestations are very common, particularly inflammatory joint pain, comorbid psychiatric disease, depressive symptoms, anxiety, sleep disturbance, et cetera, is an issue. And potentially cannabis has a role in some of those problems that we see.
Dr Kinnucan:
Yeah, Ray, I think you're bringing up an important point, that we have to really kind of think of patients beyond just their gut and their gut symptoms. Patients have reported improvement in joint pain in the studies, and so there might be benefit there; whether it's treating the underlying inflammatory aspect to the joint pain is unlikely. And I think that the studies that have been done in more inflammatory polyarthropathies like ankylosing spondylitis or patients with rheumatoid arthritis have shown symptom improvement, but similar to IBD have not shown that objective change in disease inflammation. You know, of course, outside of those extraintestinal symptoms, anxiety patients report that they actually take cannabis, at least in the general population, to improve anxiety. However, there is an association with worsening anxiety with use of cannabinoids. And if I think the most important thing is to address that that patient has anxiety and or depression and being, get them the right people, right?
As a gastroenterologist, I'm not the right person to be having more in-depth conversations about someone's uncontrolled anxiety or depression, but it is my job as their inflammatory bowel disease specialist to make sure that they have those resources. I think it's a bandaid, and it can make it worse in some patients, and most psychologists and psychiatrists would advise against substance use in terms of managing solely managing anxiety. So maybe as an adjuvant therapy—a psychiatrist would probably slap my hand for saying that. But certainly they need probably better primary therapy for anxiety or depression. It certainly shouldn't be used as the sole coping mechanism for those things.
Dr Cross:
It's funny when you mentioned psychiatry, I don't think I've ever talked to a psychiatrist who ever advocates for anything other than conventional antidepressants. And I agree with you. I think for someone who has significant anxiety and depression, I feel uncomfortable with cannabis being a long-term solution for them. But for someone who has fibromyalgia, inflammatory joint pain, maybe just bad osteoarthritis, like I have someone who's having trouble sleeping, who can take a little bit of a dose at night to sleep better, I feel much more comfortable in that situation than, as you said, with someone with significant anxiety depression. They need a professional to help them manage their symptoms.
Dr Kinnucan:
You know, you brought up sleep, Ray, and so outside of anxiety and depression, sleep was actually another highly cited reason that people in kind of the general community are using cannabis and usually using more on the cannabis indica type of strain as opposed to the cannabis sativa. Early studies in this space, not necessarily just in IBD, but in this space actually showed that very low dose can improve objective sleep parameters, right? So we both know that when it comes to sleep, people either feel like they're sleeping better or they actually are sleeping better, right? There's more of that objective improvement. And so both can happen with very low doses but that's not usually how it's being used. Patients are using moderate to higher doses of cannabinoids. And then if they start to use it more than 5 times a week, you can actually increase the amount of objective sleep changes that are on the negative side. You can actually worsen your sleep quality. And then if you withdraw, cannabis, patients can actually have a withdrawal syndrome for up to 45 days.
So I think we have to, you know, be cautious in that sleep. And I had a sleep expert, Dr. Goldstein at University of Michigan, give me sort of like, what are you all saying in your clinic when it comes to sleep and they actually advocate avoiding using substances, right? A lot of people will drink alcohol to help them sleep, or they're using cannabis and they're escalating the dosing that they'll need to achieve the same effect, and that actually can actually worsen their overall objective sleep parameters. So not sure that it's the best option for patients; certainly better than taking a daily Benadryl or maybe a sleep aid, but there are some potential things that we should caution our patients on with daily use.
Dr Cross:
Right. Before we go to the final few questions, I just want to remind our listeners that IBD Drive Time is sponsored by Advances in IBD and we are having our regional Advances in IBD courses this year again, and I'm very privileged to cochair those with Tina Ha, who's at Mayo-Arizona. The first AIBD regional will be held April 5th and April 6th in Nashville. And that's going to be a great course. We've done some changes to the format. We have more local regional faculty, so we're excited to put these out to the listeners. So hope to see you in Nashville.
So you talked about sativa, indica, like there's definitely different strains, but smoking, inhaling, mints, edibles—like what do we know about that? I mean, as far as like our patients, is there any specific form, of cannabis that is preferred?
Dr Kinnucan:
Short answer? No. So certainly we would rather, if patients are going to utilize cannabis, to have them use it in an edible form as opposed to an inhalation form, just because of some of the risks that come with, you know, the high level of temperature smoking of cannabis. But you're right, there are lots of formulations. So not only are there different strains, you mentioned sativa indica, there's also Russ, which is a high flowering plant that's often bred with either of those to help improve production. There's different routes, there's different formulations and combinations of THC and CBD. And so even the same strain could have high THC and low CBD or one could have the opposite. There's you know more utilization of something called Delta 8, which is actually CBD, which is legal in many states based on the farm bill, that has been converted to THC chemically and can have various properties that are actually amplified from Delta 9, which is one of the cannabinoids found in cannabis.
The randomized studies that have been done, the 8 that have been done across IBD really looked at different formulations. They looked at different routes of administration. They looked at CBD only. They looked at THC only. They looked at combination, low dose, and high dose. And so the challenge there is with all those different formulations how do we kind of look at the output? It's not like we're giving drug at 600 milligrams and looking at outcomes. We're looking at a lot of different things that are probably not very similar to each other in terms of how they impact the body. And so we don't know. So patients will come and say, where do I start? And I, you know, given the evidence that we don't really know what the best starting dosage is, I do say if they are looking to have more sustained relief of symptoms then an edible form, which has a longer half-life might be a better formulation than inhalation, which is pretty quick onset, but then has a shorter half-life.
We actually studied this in New York. We looked at a dispensary and what they were giving out to patients coming in with IBD and other, another chronic symptom, usually chronic pain. And the doses that they're giving out from this dispensary, they don't even know they're giving out doses that were significantly lower than what we were even studying in the clinical trials. So I, I don't even think the dispensaries know. It's sort of a trial and error.
I tell patients if they're cannabis naive to start low from a THC standpoint and sort of build up, otherwise they may experience more side effects from the product. But, you know, because it's federally still illegal, even though it's a Schedule 3 substance as of 2024, there can be legal implications for us as providers in terms of recommending cannabis or having recommending dosing. So really it's an opportunity for me to educate. I never recommend, but I can educate patients about what we know and kind of where to start. There's never been anybody that has been prosecuted from a medical standpoint, but it's always a risk because it's not an FDA-approved therapy. So just caveat to our listeners.
Dr Cross:
Okay. And so we're going to, the next to final question will be how you and I position this in our practice and what we tell patients. But how about risks?
Dr Kinnucan:
So I think you know, nothing is risk-free, right? You know, the number one cause of liver failure and from a medical standpoint is Tylenol, right? And everyone thinks of Tylenol is pretty, you know, low risk. There are risks associated with cannabis use. The risks you know, are mainly patients not disclosing that to us or that they're using it to mask symptoms and we're not evaluating their IBD. That's a lot of the risks that I think about when I think about risks. There are some drug interactions, and so it's important if patients have polypharmacy that there is a clear understanding where there might be interactions. One of the things that you think about is tacrolimus. So we give tacrolimus sometimes to treat inflammatory bowel disease, and there is a pretty strong interaction between cannabis and tacrolimus. And so we wouldn't want patients to become toxic without knowing that they're taking a therapy. There's a risk for worsening anxiety and depression. There's risk for kind of this being quote, the gateway drug to using other substances to achieve a similar level of kind of clinical euphoria. There's, you know, been some small risks in general population about motor vehicle accidents with alcohol. And we certainly know that the surgeon general is warning now with alcohol use, if there's an increased utilization, there is an interaction between cannabis and alcohol that can potentiate the effects.
You know, I think main risk that we see in our GI clinics, I don't know about you, Ray, but cannabis hyperemesis syndrome is a real thing. It's now got, you know, criteria to diagnose it, but patients who use daily, especially young men, can come in pretty miserable, multiple ER trips requiring intervention with fluids. And truthfully, the treatment for this is stopping cannabis, but it's hard for patients to do that if they've been using it for medicinal purposes. Overall low risk. But there are some, you know, things, impacts, that can happen. Certainly. Other things I counsel on is, I know you'll ask this at each of your visits, is what are their family planning goals? We certainly don't want patients using regular cannabis that have active plans to conceive. T hat would be a contraindication as well.
Dr Cross:
I mean, the other things I've been taught that I tell them, and particularly people that are under 20, under 27, is that neurocognitive development isn't complete until around age 26. And there's maybe some evidence that high use can impact that. And certainly if you're smoking marijuana, if you're smoking joints, there can be some respiratory consequences of that, right? As opposed to some of the other formulations. As far as positioning, maybe I'll go first. I think the first thing that we all should do is we should be open to patients that we're not going to judge them about use, that we want to know what they're using, and that includes marijuana and other things, right? We want them to feel open and honest, and I make it clear to them that I'm not judgmental, that I'm not anticannabis. And I think for, patients that have chronic symptoms that we don't have good solutions for, or as a bridge to an advanced therapy kicking in, supplemental use of this to try to help patients feel better to me in moderation is reasonable. Although I have no idea what formulation to tell them to use what ratio of CBD to THC, like I can't tell them. And I agree with Jami, like for mental health symptoms, I feel very uncomfortable because I feel like that should be addressed by a mental health professional, but as bridge supportive treatment and so forth that's how I view it. Jami, what's, what's your approach?
Dr Kinnucan:
We're very much in line there. I think when patients, it's always the last question as they're leaving, right, is Dr. Kinnucan, and what are your thoughts on cannabis? And, you know, they'll google this and, and see that you and I have talked about this. And so you might start to see more patients that are interested in using cannabis. The first question I'll ask them is, why are you interested in using this? And if they tell me is that they want this to be their primary treatment for their IBD, that really opens up an opportunity for me to educate them about what we know and that I'm not anticannabis, or I'm not saying that cannabis can't possibly be effective. What I'm saying is in cannabis in the current form from a dispensary is not targeting the endocannabinoid receptors in a meaningful way that it's resulting in reduced inflammation, right?
So that's what we know. If they're telling me that they, you know, they can't function, they're not eating, they are not sleeping, they have chronic pain, they're having, you know, unrelenting diarrhea and we've tried other, you know, effective medical strategies to deal with those symptoms, I agree with you, I'm a hundred percent that if this is improving their quality of life, if they're going to work, if they're able to function then I'm absolutely supportive of using this as an adjuvant approach.
So for our listeners is I think the most important question is why are you hoping to add cannabis to your regimen? If patients say, I just want to get high, then that's, that's not a medical reason, right? But if they're really interested in treating medical symptoms with it, I'll educate them about what we know. And then certainly you know, discuss some of the risks that you and I talked about today and tell them that I'm very much supportive of looking at opportunities to target the endocannabinoid receptors in a more meaningful way. And if they want to contribute to research in that that I'd be happy to partner with them. So that's always a segue into trying to get more interest into those endocannabinoid receptors, where to really think is where the money is.
Dr Cross:
Alright, Jami, this has been awesome, but now the fun question. So tell the listeners and me something about yourself that we may not know. What's your Kinnucan fun fact?
Dr Kinnucan:
You might know this, but I was, before my adulthood, I was a competitive ice skater. I was a figure skater, right?
Dr Cross:
Know that. I did not know that.
Dr Kinnucan:
No. Yeah. So I just was racing on ice skates this weekend. Certainly my over 40-year-old body does not have the same muscle memory as it did when I was 15, but I can still do some tricks.
Dr Cross:
I think I knew you were an athlete, but I didn't know figure skating. If I was going to guess, I would've said you were a swimmer. But I did not know ice skating. So that is news.
Dr Kinnucan:
Fun fact. What's your fun fact, Ray?
Dr Cross:
Oh, when I did this the first time, I told people that I made my own pickles because I had this amazing cucumber yield one year and needed something to do with it. And a friend from AbbVie actually gave me his grandmother's cucumber brine recipe. So I made cucumbers for several years, and now I can't grow cucumbers hardly at all. So I'm not pickling very much anymore, but that was one of my fun facts. I have many, but I'm going to save those for future episodes,
Dr Kinnucan:
I love that. Well, thanks for having me today.
Dr Cross:
All right, Jami, this is great. Thank you for doing this. I'm sure this is going to be a popular episode and we'll hope to have you back soon on IBD Drive Time.
Dr Kinnucan:
Sounds great. Thanks Ray.
