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14 doctor focus cannabis patient care | vol. 3 no. 2 cannapatientcare.com Very little clinical trial data on the effects of cannabis for other specific autoimmune conditions is available, though plenty of data supports the use of cannabis to treat symptoms such as pain and itching. Readers of this publication didn't need the 2017 National Academies of Sciences, Engineering, and Medicine report to tell us that they found conclusive ev- idence that cannabis could effectively treat chronic pain (8)— pain is the most common reason people use cannabis for ther- apeutic purposes (9), and with or without placebo-controlled trials, they probably wouldn't be doing so if it wasn't helping. It's important to note that without cannabis as a first-line or even second-line treatment for pain in people with autoim- mune conditions, opioids are often the only effective option. One study found that 40% of patients with rheumatoid arthri- tis used prescription opioids regularly (10). The consequenc- es of long-term opioid use, including increased sensitivity to pain, hormone disruption, disturbed sleep, problematic use, and overdose, are finally common knowledge among clinicians and patients alike. While cannabis has been shown again and again to work as a tool for helping patients decrease and dis- continue opioids, it's even better when it's used to avoid the need to start opioids in the first place. Less commonly known, however, are the benefits of can- nabis for treating pruritis (itching), a common manifesta- tion of autoimmune conditions in the skin. Substantial pre- clinical evidence indicates the cannabinoids work via CB1 and CB2 receptors in itch-related nerves fibers in the skin to sup- press signaling and via CB1 receptors in the spinal cord and brain to decrease the intensity of the sensation. Human clin- ical studies in a variety of skin conditions, including psoriasis and eczema, have consistently shown significant reductions in itching and scratching using both topical and systemic can- nabinoid treatments (11). Not surprisingly, the topical treat- ments also resulted in decreased signs of inflammation. Crohn's disease and ulcerative colitis, collectively known as inflammatory bowel disease (IBD), are autoimmune diseases that affect the gastrointestinal tract. People with IBD experi- ence both gastrointestinal symptoms like abdominal pain, di- arrhea, bleeding, and weight loss, as well as systemic symp- toms like joint pain and fatigue. Symptoms can be present daily but typically cycle through "flares" of exacerbation. The goal of treatment is not only to address symptoms, but also to prevent the need for surgical removal of the intestines and other complications including nutrient deficiencies and weight loss, anemia, fistulas, and more. Little high-quality human research has examined the im- pact of cannabis in these conditions, and the studies that have been performed, in my opinion, have not used practical cannabis dosing strategies—low dose CBD isn't going to cut it (12). Surveys of patients with these conditions, however, con- firm what I've observed in my clinical practice: most patients with IBD who try cannabis, find it helpful and continue to use it. A survey of US patients with IBD found that 80% of those who tried cannabis reported benefits in their condition. Inter- estingly, 21% of those living in states with both medical and adult-use cannabis laws used adult-use products specifical- ly for IBD without their clinician's knowledge. The most com- monly reported benefits (13) were related to pain (68%), appe- tite (49%), anxiety (48%), fatigue (26%), stool frequency (23%), weight gain (20%), and blood in stool (5%). In a large, recent survey of people with IBD in Australia (14), 25% of respondents had used cannabis for their condition, and 93% of them endorsed cannabis as effective in symptom man- agement. The most common symptoms helped by cannabis were abdominal pain, stress, sleep issues, cramping, anxiety, bloating, depression, reduced appetite, and diarrhea—amongst many others. The authors noted, "the magnitude of self-report- ed symptom improvement in the present survey was surpris- ingly high. Symptom improvements of the magnitude reported in this study are rarely seen in any therapeutic intervention." For symptomatic treatment, cannabis often sounds too good to be true. When asked if cannabis can help with—fill in the blank: pain, itching, stiffness, spasms, redness, hypersensitivity, diarrhea, cramping, anxiety, fatigue, insomnia, anxiety, and so forth—the answer is yes, in most people. Of course, not everyone responds to cannabis, and in some, the results are modest. In others, the benefits are profound, life-changing, and often allow patients to discontinue other treatments that have significant side effects. While treating symptoms is important, preventing them may be even more helpful for people with these conditions. Cannabis, Stress, and Autoimmune Disease Anyone with an autoimmune disease will confirm that psycho- logical stress plays a major role in their symptoms, and that high stress events can trigger a flare-up or even a relapse of their condition. Most clinicians who treat patients with autoimmune diseases will confirm that they see more flare-ups during times of major stress. It's well-known that stress impacts the func- tion of the immune system, but the association of stress and stress-reduction techniques with symptom severity in autoim- mune diseases has not yet received substantial attention of researchers in the field, and seldom receives the attention of clinicians caring for these patients. In one study of 92 patients with rheumatoid arthritis, psychologic stress was reported to be the most common reason for disease flares (15). As mentioned above, psychological stress is also impli- cated in the development of autoimmune diseases. A re- cent retrospective Swedish cohort study compared the inci- dence of autoimmune disease in more than 100,000 people with stress-related disorders such as post-traumatic stress disorder (PTSD), adjustment disorder, and acute stress reac- tion with the incidence of autoimmune disease in more than 126,000 of their full siblings and over 1 million matched con- trol subjects without a stress-related disorder. During an