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Original Articles IMAJ • VOL 13 • August 2011
well-being before and after cannabis use on a Visual Analog smoke through water (“bong”), and one patient preferred to
Scale. The scale ranged from 0, which represented “very poor consume it orally. Most smoked between one and three “joints”
general well-being” to 10, indicating “excellent well-being.” a day, but one patient with chronic pain smoked seven joints a
Whenever possible, medical documents were reviewed for day. Since one cigarette contains about 0.5 mg of THC, patients
objective signs of disease severity, such as number of hospital were using 0.5–1.5 mg/day THC, with the exception of one
admissions and use of other drugs, particularly steroids. The patient who was using 3.5 mg. The average duration of can-
dose and form of administration of cannabis were docu- nabis use was 2.14 years (range 3 months to 9 years). In 14
mented. The study was approved by the institutional ethics patients the duration of cannabis use was less than a year.
committee of our hospital. All patients stated that consuming cannabis had a positive
effect on their disease activity. This is also reflected in the
Visual Analog Scale, which increased from 3.1 to 7.3. The
Results Harvey Bradshaw index decreased from 14 ± 6.7 to 7 ± 4.7
Thirty patients with CD who were using cannabis were inter- (P < 0.001) [Figure 1]. The mean number of bowel move-
viewed. The average age was 36 years (range 21–65 years) ments decreased from eight to five a day and the need for
and four were female. One patient with CD had a history other drugs was significantly reduced [Table 1]. Of particular
of partial pancreatectomy for serous cystadenoma, one had interest is the observation that cannabis may have a steroid-
asthma and two had hypertension. All other patients were sparing effect, since the number of patients requiring steroid
generally healthy apart from their CD. Before the use of treatment was reduced from 26 to 4. Fifteen of the patients
cannabis, five patients had undergone right hemicolectomy, had 19 surgeries during an average period of 9 years before
three had resection of the terminal ileum, two had resection cannabis use, but only 2 required surgery during an aver-
of a proximal section of the ileum, and three had drainage age period of 3 years of cannabis use. In nine patients can-
of a perianal fistula. One patient with severe colitis had a nabis treatment did not induce a significant improvement,
total proctocolectomy with ileoanal anastomosis. After the as reflected by a change of less than 4 points in the Harvey
operation she developed perianal disease and the diagnosis Bradshaw index. Three of these patients did not respond to
was changed from ulcerative colitis to Crohn’s disease. Of the
THC = Δ9-tetrahydrocannabinol
15 patients who had an operation before using cannabis, 2
(13%) required another surgery during an average time of 2
Figure 1. Harvey Bradshow index before and after cannabis use
years while on cannabis. The average duration of disease was
11.3 years (range 1–41 years). Twenty patients with CD had 30
inflammation of the terminal ileum, 5 had inflammation of Before cannabis
25
the more proximal ileum and 8 had Crohn’s disease of the After cannabis
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IMAJ • VOL 13 • August 2011 Original Articles
any other medical therapy, including TNF antagonists, and the efficacy of cannabis in Crohn’s disease. The restraint from
are now awaiting surgery. the use of an illegal drug may have played a role.
The observed beneficial effect in this study may be due to
the anti-inflammatory properties of cannabis, but additional
Discussion effects of cannabinoids may also play a role. Cannabinoids
In this study, we describe 30 patients with CD for whom the influence gastrointestinal motility and, in particular, have an
use of cannabis ameliorated disease activity and reduced the anti-diarrheal effect, as observed in mice injected with chol-
need for other conventional medications. This is the largest era toxin [12]. The central effect of cannabinoids may induce
and, to the best of our knowledge, the first reported series a sensation of general well-being, which could contribute to
of CD patients treated with cannabis. It is a retrospective the feeling that cannabis use is beneficial. However, this gen-
observational study and as such is not a replacement for a eral effect wears off with time as tolerance develops, while the
prospective placebo-controlled study. There may be a popula- positive effect of cannabis on disease activity in our patients
tion bias in the sense that some people may be more attracted was maintained for an average period of 3.1 years.
to the possibility of smoking cannabis than others. This may One of the reasons that cannabis is unappealing to many
explain the over-representation of young males in our study patients is that it is administered by smoking. Smoking in
population. Also, there may be patients who tried cannabis general is unacceptable to both medical professionals and
and whose condition did not improve; they would be lost to many patients. The negative effect of tobacco smoking on
follow-up and are not represented in our study. However, the Crohn’s disease is also well known. Several studies demon-
benefit reported by most of the patients in our study suggests strated a dose-related adverse effect of cannabis on large
a possible significant therapeutic potential. Due to the retro- airway function, but not on small airway function, which is
spective nature of our study there may be a bias in recalling compromised by tobacco smoking [13,14]. Smoking cannabis
disease activity. However, several facts point to an objective is the preferred mode of consumption because upon smok-
benefit of cannabis use. The observed reduced use of steroids ing, blood levels of cannabinoids rise rapidly and a central
(from 26 to 4 patients) [Table 2] and other drugs may point effect is achieved quickly. However, an anti-inflammatory
to an objective beneficial effect of cannabis. Whereas 25% effect, especially in the gut, may be achieved equally well by
to 38% of operated Crohn’s disease patients are expected to consuming cannabis orally.
require a second operation within 5 years of the first [11], Although many side effects were connected with cannabis
only 2 of 15 patients (13%) who had surgery before cannabis use, most of them were in people who consumed other drugs
consumption required surgery while consuming cannabis. and alcohol together with cannabis. When consumed alone,
Larger numbers and longer follow-up are needed to verify the safety profile of cannabis is very good [15]. Wang et al.
whether use of cannabis reduces the need for surgery. [16] reviewed 31 studies of medical cannabis use and found
The effects of cannabinoids on the immune system are that 96% of 4779 adverse events were minor. The relative risk
diverse and include modulating proliferation of B cells, T cells, for serious adverse events was 1.04, which was not different
and natural killer cells, modulating production of antibodies between the placebo and study groups. Cannabinoids may
and cytokines, and regulating functions of NK cells, mac- therefore be a potential addition to the currently limited
rophages, T helper cells, mast cells and dendritic cells [10]. arsenal of medications used to treat IBD. On the other hand,
Although anti-inflammatory effects of cannabis have been because the use of medical cannabis may be exploited by
described previously, there are no systematic descriptions of drug abusers, extra caution is necessary before cannabis can
TNF = tumor necrosis factor
be recommended to patients. A placebo-controlled study is
NK = natural killer needed to fully investigate the therapeutic value of cannabis
for the treatment of Crohn’s disease.
Table 2. Medical treatment before and after cannabis use (n=30)
457
Original Articles IMAJ • VOL 13 • August 2011
References receptor (CB(2)) protects against experimental colitis. Inflamm Bowel Dis
2009; 11: 1678-85.
1. Wingerchuk D. Cannabis for medical purposes: cultivating science, weeding
out the fiction. Lancet 2004; 364: 315-16. 10. Dai Lu V, Kiran V, Richard I, et al. The cannabinergic system as a target for
anti-inflammatory therapies. Curr Topics Med Chem 2006; 6: 1401-26.
2. Baker D, Pryce G, Giovannoni G, et al Therapeutic potential of cannabis.
Lancet Neurol 2003; 2: 291-8. 11. Whelan G, Farmer RG, Fazio VW, et al. Recurrence after surgery in Crohn's
disease. Relationship to location of disease (clinical pattern) and surgical
3. Williamson EM, Evans FJ. Cannabinoids in clinical practice. Drugs 2000; 60
indication. Gastroenterology 1985; 88: 1826-33.
(6): 1303-14.
12. Izzo AA, Capasso F, Costagliola A, et al. An endogenous cannabinoid tone
4. Izzo AA, Camilleri M. Gastrointestinal and liver diseases: basic and clinical
attenuates cholera toxin-induced fluid accumulation in mice. Gastroenterology
aspects: emerging role of cannabinoids. Gut 2008; 57: 1140-55.
2003; 125: 765-74.
5. Hall W, Solowij N. Adverse effects of cannabis. Lancet 1998; 352: 1611-16. 13. Aldington S, Williams M, Nowitz M, et al. Effects of cannabis on pulmonary
6. Nahas G, Sucui-Foca N, Armand JP. Decrease of cellular immunity in hashish structure, function and symptoms. Thorax 2007; 62 (12): 1058-63.
(marihuana) smokers. C R Acad Sci Hebd Seances Acad Sci D 1973; 277: 979-80. 14. Hancox RJ, Poulton R, Ely M, et al. Effects of cannabis on lung function: a
7. Sofia RD, Knobloch LC, Vassar HB. The anti-edema activity of various naturally population-based cohort study. Eur Respir J 2010; 35 (1): 42-7.
occurring cannabinoids. Res Commun Chem Pathol Pharmacol 1973; 6: 909-18. 15. Kumar RN, Chambers WA, Pertwee RG. Pharmacological actions and
8. Pacifici R, Zuccaro P, Pichini S, et al. Modulation of the immune system in therapeutic uses of cannabis and cannabinoids. Anaesthesia 2001; 56: 1059-68.
cannabis users. JAMA 2003; 289: 1929-31. 16. Wang T, Collet JP, Shapiro S, et al. Adverse effects of medical cannabinoids: a
9. Storr MA, Keenan CM, Zhang H, et al. Activation of the cannabinoid 2 systematic review. CMAJ 2008; 178 (13): 1669-78.
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“Experience is not what happens to a man; it is what a man does with what happens to him”
Aldous Huxley (1894-1963), British novelist, most famous for his classic Brave New World
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