Full length articlePatterns of cannabis use in patients with Inflammatory Bowel Disease: A population based analysis
Introduction
While tobacco use has been shown to be an important risk factor for the development and severity of Crohn's disease, as well as having beneficial effects on the course of ulcerative colitis, the role and patterns of cannabis use amongst patients with Inflammatory Bowel Disease (IBD) remains poorly defined (Karczewski et al., 2014). Marijuana is the generic term for preparations derived from the Cannabis sativa plant. Marijuana is a complex mixture of over 60 chemicals, the most psychoactive of which is tetrahydrocannabinol (THC), which is found in a resin on the flowering tops and upper leaves of the female plant and can be consumed through smoke inhalation or ingestion (Hall and Degenhardt, 2009). Hashish is also derived from the C. sativa plant and thus considered by the Food and Drug Administration as in the same class as marijuana, however it is a slightly different preparation of the stalked resin glands that results in higher concentrations of THC than marijuana. The recreational use of cannabis has been well described in the general population, as has its potential for medicinal use in symptom control in disorders such as cancer, HIV, and multiple sclerosis (Baker et al., 2003, Page et al., 2003, Woolridge et al., 2005). However, according to federal law, recreational marijuana remains a Schedule 1 drug according to the United States Controlled Substance Act, which places it in a category of substances that have a high potential for abuse and no accepted medical indication. Recent epidemiological studies have shed some light on the prevalence and potential therapeutic benefits of marijuana use in patients with Inflammatory Bowel Disease. Recent studies estimate between 10 and 12.3% of IBD patients are active cannabis users and surveys conducted in patients with IBD report between 43.9 and 51% of patients with IBD having ever used cannabis at some point in their lifetime (Garcia-Planella et al., 2007, Lal et al., 2011, Naftali et al., 2011, Ravikoff Allegretti et al., 2013). Epidemiological data suggests between 10 and 50% of patients with IBD use marijuana for disease symptom control, with symptoms cited including abdominal pain, nausea and diarrhea (Lal et al., 2011, Naftali et al., 2013, Ravikoff Allegretti et al., 2013).
These perceived clinical benefits have found scientific support in animal models which utilized knockout mice to characterize the anti-inflammatory properties of cannabis at the cannabinoid 1 (CB1) and cannabinoid 2 (CB2) receptors, as well as in small clinical trials, which have suggested that marijuana may induce remission in patients with Crohn's Disease who have failed medical therapy (Borrelli et al., 2009, Lahat et al., 2012, Naftali et al., 2011, Naftali et al., 2013). While the precise mechanism of cannabis’ contribution in IBD symptom control remains somewhat elusive, experimental models suggest that upon CB2 receptor activation T cells undergo apoptosis and decreased proliferation (Wright et al., 2008). Additionally, there is diminished recruitment of neutrophils, T cells and macrophages to the inflamed colon. CB receptors have also been found in the enteric nervous system (ENS), which controls gut motility and secretion. With the up-regulation of inflammatory mediators activated by the ENS during IBD, activation of CB1 receptors by cannabis may reduce hypermotility thereby contributing to the reduction in nausea and diarrhea reported by patients (Abalo et al., 2012).
The first study to look at marijuana's therapeutic effects in patients with IBD was a retrospective observational study by Naftali et al. (2011), which reported disease severity indices before and after marijuana use in thirty patients with Crohn's disease (CD) who had failed conventional treatment. All patients reported a positive effect on disease activity, a reduction in the number of daily bowel movements, and a reduction in the need for additional drugs including steroids. Shortly thereafter Lahat et al. (2012) published a prospective study evaluating quality of life before and after treatment with cannabis, as defined by the SF-36 Health Survey, EQ-5D Health Survey and the Harvey Bradshaw Index. After three month of treatment with cannabis, patients reported improvement in general health perception, social functioning, ability to work, physical pain and depression. Naftali et al. (2013) published the first prospective placebo-controlled study, which evaluated 21 patients with Crohn's disease unresponsive to standard IBD treatment. Authors compared outcomes in patients treated with marijuana for 8 weeks with those treated with placebo cigarettes. They found clinical and steroid sparing benefits to treatment with marijuana, reporting complete remission in 45% of patients in the study group vs. 10% of patients in the control group (p = 0.43). They found a clinical response (defined as a decrease in the Crohn's Disease Activity Index (CDAI) score of >100) in 90% of the study group vs. 40% of the control group (p = 0.028), and a mean reduction in CDAI of 177 ± 80 in the study group and 66 ± 98 in the placebo group (p = 0.005). The authors also reported that all three patients in the treatment arm who were steroid dependent were able to be weaned off and two opioid-dependent patients in the treatment arm successfully stopped narcotics.
While the science is persuasive and the findings of early studies suggest there is therapeutic benefit to marijuana use in patients with IBD, the small number of patients precludes making generalizations about patterns of marijuana use in patients with IBD. Our aim was to determine the prevalence of marijuana use and to characterize its association with IBD using a population-based survey sample of patients with IBD.
Section snippets
Sample population
The National Health and Nutrition Examination Survey (NHANES) is a major program of the National Center for Health Statistics (NCHS), part of the Centers for Disease Control and Prevention (CDC), and is responsible for producing vital health statistics for the US population. The yearly survey is unique in that it performs medical interviews, physical examinations and laboratory testing on a nationally representative sample of US citizens. For 2 years (2009 and 2010) a module was added to the
Demographic characteristics (Table 1)
Table 1 outlines the demographic and socioeconomic characteristics of the subjects stratified by IBD status. There were no significant differences in the demographic characteristics, and the two groups were well matched for age, gender, weight and height, race and education. Subjects with IBD tended to score higher on the Median Depression Score, participate less frequently in vigorous exercise, were more likely to have had a period in their life where alcohol consumption exceeded 5 alcoholic
Discussion
Few studies have aimed to quantify and characterize patterns of marijuana use amongst patients with IBD. Our data shows that in a large scale population-based survey, subjects with IBD have a higher prevalence of ever having used marijuana, start at a younger age, and use larger quantities than controls without IBD. After adjustment for relevant confounders in logistic regression the odds of marijuana/hashish use was minimally more than non-IBD subjects. Interestingly, control subjects use
Role of funding source
Nothing declared.
Contributors
All authors have made substantial contributions to the conception and design of this study involving the acquisition of data, analysis and/or interpretation of data, the drafting and revision of the article with critical revision for intellectual content, and the final approval of the version that is being submitted.
Alexandra Weiss: article selection, article retrieval, manuscript writing and data interpretation.
Frank Friedenberg: statistical analysis, data interpretation, manuscript writing
Conflict of interest statement
This manuscript, including related data, figures and tables has not been previously published and this manuscript is not under consideration elsewhere and there is no financial conflict of interest for all authors.
Alexandra Weiss: none.
Frank Friedenberg: none.
Acknowledgements
N/A.
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