April 2019 Issue

Cannabis Use for Treating Disease
By Janice Newell Bissex, MS, RDN
Today’s Dietitian
Vol. 21, No. 4, P. 36

The compounds in cannabis and CBD have been shown to reduce symptoms in various disease states.

“Wow, I’m not in pain,” said my father minutes after taking two puffs on his new cannabis vape pen in 2016.

I couldn’t believe it.

After years of debilitating pain and equally debilitating side effects from his pain medications, including constipation requiring a hospital stay, we were running out of options. On a whim, I asked my dad’s doctor if medical marijuana was something we should consider, and he replied, “I think that’s a great idea.”

I was shocked—and worried. First, I knew nothing about the medical use of marijuana, and second, I was unsure whether my dad would agree to try it.

Both my parents and I were reluctant at first. Then I did some research and became convinced that cannabis might help. Once we got dad certified as a medical marijuana patient in Massachusetts, he went from agonizing pain to finding relief in a matter of minutes. My shock slowly turned into a bit of anger that no one had suggested medical cannabis before. My father’s journey using cannabis and CBD (cannabidiol) for symptom management, appetite stimulation, and pain relief was the catalyst to my career change.

After I was trained on the science behind the health and wellness benefits of cannabis, I became certified as a Holistic Cannabis Practitioner through the Holistic Cannabis Academy. Jannabis Wellness was founded to help clients who suffer from pain, anxiety, insomnia, muscle spasms, depression, arthritis, autoimmune diseases, autism, inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), and other debilitating conditions find relief using CBD and cannabis.

My mission now is to educate health professionals and consumers about the health and wellness benefits of cannabis with information on access, proper cannabinoid ratios, dosing, best consumption methods, potential drug interactions, and cooking with cannabis.

History of Cannabis Use
The first documented use of cannabis dates back to 4000 BC in Chinese medicine.1 Its medicinal use continued for thousands of years. Queen Victoria reportedly used cannabis tincture to treat her menstrual cramps around the 1850s. Doctors commonly prescribed cannabis. In fact, it was included in the US Pharmacopeia with indications for use and dosing information from 1850 until 1942.

What happened to cause this plant-based medicine to fall out of favor in the early 1900s? There are reasons, both political and racial, that are beyond the scope of this article. Suffice it to say, it wasn’t a medical decision to outlaw cannabis.

In 1970, cannabis was classified as a Schedule I substance (along with heroin and LSD), citing “no medical benefit and a high potential for abuse.”2 Despite calls for rescheduling by the New England Journal of Medicine in 1997, and a 1999 report by the Institute of Medicine stating that cannabinoids (compounds found in the cannabis plant) showed promise in treating nausea, appetite loss, pain, and anxiety, cannabis remains federally illegal. This classification is one reason we haven’t seen more research on cannabis in the United States.

However, that may be changing. In January 2019, the University of California Berkeley announced the creation of its new Cannabis Research Center to explore the environmental and social impacts of marijuana legislation.3

When scientists from the National Institutes of Health discovered that cannabinoids, in particular CBD, showed promise in the treatment of degenerative brain diseases, they applied for a patent in 1999 to control the research on CBD and cannabinoids. In 2003, the US Department of Health and Human Services was awarded Patent 6630507B1, titled “Cannabinoids as Antioxidants and Neuroprotectants.”4

Scientists stated the following in the patent application: “The cannabinoids are found to have particular application as neuroprotectants, for example in limiting neurological damage following ischemic insults, such as stroke and trauma, or in the treatment of neurological diseases, such as Alzheimer’s disease, Parkinson’s disease, and HIV dementia.” The patent also states, “No signs of toxicity or serious side effects have been observed following chronic administration of cannabidiol to healthy volunteers, even in large acute doses.”4 So, both scientists and the government agree that cannabinoids in the cannabis plant have medicinal properties and aren’t harmful for human consumption.

Cannabis 101
There are more than 400 active compounds in the flowering cannabis plant. Cannabinoids are the major components, the two most well known and studied being delta-9 tetrahydrocannabinol, commonly referred to as THC, and cannabidiol, known as CBD. Hemp is also part of the same family as Cannabis sativa L, but contains less than 0.3% THC. Cannabis can range in potency from less than 6% up to 30% THC. CBD can be found in both cannabis and hemp plants.

THC is best known for its psychoactive effects—too much will get you “high” or “stoned”—but it has anti-inflammatory, antispasm, antinausea, analgesic, and bronchodilator effects. It also can stimulate appetite and relax muscles.

Nonintoxicating CBD has analgesic, antianxiety, neuroprotective, antidepressant, anti-inflammatory, antiseizure, antispasm, and antinausea effects. It also may improve blood sugar control and bone health.5,6

Additional active components of cannabis include terpenes (common aromatic, organic compounds found in all plants) and flavonoids. The health-promoting terpenes found in cannabis include beta-caryophyllene, linalool (found in lavender), myrcene, limonene (found in citrus fruits), and pinene. Beta-caryophyllene is a powerful terpene that contributes to the sensation of pain relief. Flavonoids also are abundant in the cannabis plant. Cannaflavin-A is one flavonoid that’s a more powerful anti-inflammatory than aspirin.

The “entourage effect” describes the synergistic interactions between cannabinoids, terpenes, and flavonoids. This is why full spectrum CBD products tend to be more effective than a CBD isolate.

The endocannabinoid system, found in humans and animals, is a biochemical system that promotes homeostasis. Discovered in 1992, this major neurotransmitter system is involved in many mechanisms, including the regulation of mood, attention, immune function, and fetal development. The system is regulated by endocannabinoids naturally produced by the body: anandamide and 2-AG. There are two predominant endocannabinoid receptors, CB1 and CB2, which are found in our brain, spinal cord, gastrointestinal tract, immune cells, and all organs in the body.

Anandamide is known as the “bliss molecule” because of its “feel good” effect. It’s a critical endocannabinoid that affects areas of the brain involved in mood, motivation, and memory. Anandamide is broken down by the enzyme fatty acid amide hydrolase (FAAH).7 If too much FAAH is produced by the body, anandamide is broken down quickly, which may increase the incidence of anxiety and depression. CBD plays a role in inhibiting FAAH, thereby increasing anandamide levels. In addition to its neuro-calming effect, anandamide activates the CB1 receptors to reduce inflammation and pain.

Implications for RDs
Nearly 55 million adults in the United States report using cannabis. There has been a 10-fold increase in cannabis use in those over age 65, which isn’t surprising since 53% of adults over 65 report experiencing pain in the previous month. As legalization spreads nationwide, it’s critical that health professionals educate themselves on the therapeutic potential of cannabis and CBD and be open to discussing this with their clients and patients.

Preliminary data show good results using CBD and cannabis for IBD/IBS, cachexia, multiple sclerosis, Parkinson’s disease, decreased appetite, nausea, pain, depression, and anxiety. Some athletes have turned to cannabis or CBD to improve performance and aid recovery due to the vasorelaxant, anti-ischemic, and anti-inflammatory effects. The neuroprotectant properties of CBD, in particular, make it a critical adjunct to therapy in traumatic brain injury and concussion. The World Anti-Doping Agency removed CBD from its prohibited substance list in 2018.8

Both THC and CBD may help stimulate appetite. THC increases ghrelin, the “hunger hormone,” which boosts appetite and may promote fat storage. THC and anandamide also activate the CB1 receptors in the brain that regulate food intake and enhance eating pleasure.9

A randomized, double-blinded, controlled crossover study conducted between 2008 and 2011 at a specialized care center for eating disorders showed a small but significant weight gain among participants who received a synthetic THC drug. The study included 24 women over age 18 who had anorexia nervosa for at least five years. They were randomized to receive dronabinol, a synthetic THC drug, for four weeks. These participants gained 0.73 kg (~1.16 lb) above placebo, which is small but significant weight gain, without significant psychotropic adverse events (p<0.01).10

There’s potential for THC use for increasing body weight in clinical populations, such as people with HIV-associated wasting syndrome, anorexia nervosa, or cancer-associated cachexia. Despite stimulating appetite, the average BMI of daily cannabis users is about 3% lower than the general population.11

Perhaps the most widely accepted use of cannabis and CBD in the medical community is with cancer patients. In a Cochrane review by Smith and colleagues in 2015, 23 trials were studied to see the effects of cannabinoids on chemotherapy-induced nausea and vomiting. Synthetic THC drugs dronabinol and nabilone were used in nine placebo-controlled trials and in 15 trials with active comparators such as chlorpromazine.

Investigators found that THC was highly effective and more efficacious than placebo and similar to conventional antiemetics in treating chemotherapy-induced vomiting and nausea. The authors concluded that cannabinoids should be considered as a tool in treating chemo-induced nausea and vomiting.12 RDs in clinical settings who commonly work with reducing or managing nausea in patients and those working in end-of-life/hospice care should be aware of this treatment option.

CBD also may be an effective adjunct to therapy in the treatment of broken bones, osteopenia, and osteoporosis. In one study, rats with broken legs healed faster, and their bones were stronger when treated with CBD compared with the control group.6,13

Since cannabis is a potent anti-inflammatory, it isn’t surprising that it may be helpful in the treatment of IBD. A survey-based study of cannabis users with IBD in the United States noted an improvement in abdominal pain, appetite, nausea, and diarrhea. In a separate prospective pilot study, IBD patients using medical cannabis for pain control experienced improvements in pain, general health perception, social functioning, ability to work, and symptoms associated with IBD.14

Cannabis vs Opioids
Contrary to what some believe, cannabis isn’t considered a gateway drug but rather an exit herb for drugs such as opioids. A 2016 report found that giving cannabis to opioid addicts decreased opioid use by 64%.15 Moreover, states that have legalized cannabis have shown a 16% to 31% decrease in opioid mortality.16

Using cannabis for pain management may stave off the need for opioids or allow a decreased dose. Cannabis also can reduce drug cravings, anxiety, pain, and mood symptoms during withdrawal.

Cannabis and Drug Interactions
The cytochrome P450 (CYP450) enzyme system in the liver metabolizes about one-half of all prescription medications. This enzyme breaks down cannabis and CBD, so it’s possible that this could affect the blood levels of certain medications. If a patient is taking a drug, such as warfarin (Coumadin) and certain antiarrhythmics, for which grapefruit is contraindicated, it’s best to proceed with caution. Using a topical that doesn’t enter the bloodstream or a tincture placed under the tongue may be a better choice than a softgel or edible that the liver processes.

CBD may work synergistically with selective serotonin reuptake inhibitors (SSRIs). Some clients may reduce their dose of these medications when taking CBD. With alcohol, THC may increase central nervous system impairment, so it’s best not to drink when using cannabis with THC. Another factor to consider is that drugs that decrease stomach acid may increase the amount of cannabis absorbed.

Methods of Administration
Many options are available for administering CBD and cannabis besides inhalation, including sublingual tinctures, topical creams, suppositories, transdermal patches, and edibles. The best delivery depends on the individual. For dosing, it’s best to start low and go slow. The rate of onset depends on many factors, including the person’s body fat percentage and individual endocannabinoid system. Fat in the diet can increase absorption and prolong the effect.

Consuming edibles (including oral capsules) is an effective way to get long-term pain relief for chronic conditions. Usual onset is 30 to 90 minutes with a 6- to 12-hour duration—the longest of all modes of administration. Inhalation—vaping or smoking—has the quickest onset (one to three minutes), which may make it appropriate for episodic pain, but the shortest duration (one to three hours).

Counseling Tips
Currently, 33 states and the District of Columbia have legalized medical cannabis. Canada and 10 US states allow adult (recreational) use of cannabis. The 2018 Farm Bill reclassified hemp as an agricultural product and legalized hemp at the federal level.

When discussing cannabis and helping clients choose CBD, it’s best to look for products from hemp that’s organically grown since cannabis and hemp are bioaccumulator plants that draw toxins from the soil. Clean extraction methods avoid the use of solvents such as hexane and butane.17

Always ask for independent lab testing to ensure that what’s listed on the label is accurate. Studies by the FDA and the American Medical Association found that 70% of CBD products on the market were mislabeled, with some containing zero CBD.18,19 Some CBD products contain a trace amount of THC, which could be an issue for those who undergo drug testing.

Up to 90% of medical doctors don’t feel confident recommending cannabis, and it’s likely a majority of dietitians feel the same. Astonishingly, only 10% of medical schools include cannabis education, and few dietetics internships teach about the benefits of medical cannabis. Because clients are looking for credible information, RDs are in a unique position to offer nonjudgmental advice and counseling about the medical benefits of cannabis and CBD, in particular as it relates to gastrointestinal issues such as nausea, IBD and IBS, pain, blood sugar control, and cancer treatment side effects.

Cannabis and CBD generally are well tolerated when used properly, with no serious adverse side effects. My hope is that RDs will join the effort to reduce the stigma and be open to cannabis and CBD as viable options in the treatment of many debilitating health conditions.

— Janice Newell Bissex, MS, RDN, is a Holistic Cannabis Practitioner at Jannabis Wellness.

References
1. Ancient history timeline. Holistic Cannabis Academy website. http://holisticcannabisacademy.com. Accessed February 7, 2019.

2. Drug scheduling. US Drug Enforcement Administration website. https://www.dea.gov/drug-scheduling

3. Loriaux A. UC Berkeley given green light to study marijuana. LabRoots website. https://www.labroots.com/trending/cannabis-sciences/13951/uc-berkeley-given-green-light-study-marijuana. Published February 1, 2019. Accessed February 7, 2019.

4. US6630507B1 — cannabinoids as antioxidants and neuroprotectants. Google Patents website. https://patents.google.com/patent/US6630507B1/en. Accessed February 7, 2019.

5. Weiss L, Zeira M, Reich S, et al. Cannabidiol lowers incidence of diabetes in non-obese diabetic mice. Autoimmunity. 2006;39(2):143-151.

6. Moore M. Cannabidiol enhances fracture healing. LabRoots website. https://www.labroots.com/trending/cannabis-sciences/8584/cannabidiol-enhances-fracture-healing. Published November 9, 2018. Accessed February 7, 2019.

7. Ahn K, Johnson DS, Cravatt BF. Fatty acid amide hydrolase as a potential therapeutic target for the treatment of pain and CNS disorders. Expert Opin Drug Discov. 2009;4(7):763-784.

8. World Anti-Doping Agency. Summary of major modifications and explanatory notes: 2018 prohibited list. https://www.wada-ama.org/sites/default/files/prohibited_list_2018_summary_of_modifications_en.pdf. Accessed February 8, 2019.

9. Soria-Gómez E, Bellocchio L, Reguero L, et al. The endocannabinoid system controls food intake via olfactory processes. Nat Neurosci. 2014;17(3):407-415.

10. Andries A, Frystyk J, Flyvbjerg A, Støving RK. Dronabinol in severe, enduring anorexia nervosa: a randomized controlled trial. Int J Eat Disord. 2014;47(1):18-23.

11. Beulaygue IC, French MT. Got munchies? Estimating the relationship between marijuana use and body mass index. J Ment Health Policy Econ. 2016;19(3):123-140.

12. Smith LA, Azariah F, Lavender VT, Stoner NS, Bettiol S. Cannabinoids for nausea and vomiting in adults with cancer receiving chemotherapy. Cochrane Database Syst Rev. 2015;(11):CD009464.

13. Schuster R. Marijuana helps broken bones heal, says Israeli scientific team. Haaretz. July 21, 2015. https://www.haaretz.com/science-and-health/.premium-marijuana-helps-broken-bones-heal-1.5377277. Accessed February 7, 2019.

14. Kinnucan J. Use of medical cannabis in patients with inflammatory bowel disease. Gastroenterol Hepatol (N Y). 2018;14(10):598-601.

15. Boehnke KF, Litinas E, Clauw DJ. Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain. J Pain. 2016;17(6):739-744.

16. Sarlin E. Study links medical marijuana dispensaries to reduced mortality from opioid overdose. National Institute on Drug Abuse website. https://www.drugabuse.gov/news-events/nida-notes/2016/05/study-links-medical-marijuana-dispensaries-to-reduced-mortality-opioid-overdose. Updated May 17, 2016. Accessed February 15, 2019.

17. Mead A. The legal status of cannabis (marijuana) and cannabidiol (CBD) under U.S. law. Epilepsy Behav. 2017;70(Pt B):288-291.

18. Warning letters and test results for cannabidiol-related products. FDA website. https://www.fda.gov/newsevents/publichealthfocus/ucm484109.htm. Updated November 2, 2017. Accessed February 14, 2019.

19. Bonn-Miller MO, Loflin MJE, Thomas BF, Marcu JP, Hyke T, Vandrey R. Labeling accuracy of cannabidiol extracts sold online. JAMA. 2017;318(17):1708-1709.