Evolving Landscape of CBD Use and Psoriatic Disease
“Welcome to this episode of Psound Bytes™, a podcast series produced by the National Psoriasis Foundation, the nation’s leading organization for individuals living with psoriasis and psoriatic arthritis. In each episode someone who lives with psoriatic disease, a loved one or an expert will share insights with you on living well. If you like what you hear today, please subscribe to our podcast and join us every month at Psound Bytes™ for more insights on understanding, managing, and thriving with psoriasis and psoriatic arthritis.”
Shiva: My name is Shiva Mozaffarian and returning today for an update on the use of cannabis-based products is dermatologist Dr. Jason Hawkes, Associate Professor of Dermatology at the University of California, Davis. Dr. Hawkes initially addressed the use of cannabis with Psound Bytes™ back in September 2020 with episode 90 “Facts About CBD Use and Psoriasis”. Dr. Hawkes has a background in translational immunology and has served as Principal Investigator and Co-Investigator for a number of pharmaceutical-sponsored and investigator-initiated clinical trial protocols. He is a member of the National Psoriasis Foundation’s Medical Board which is preparing to release results of a survey addressing attitudes and knowledge of medical cannabis use (also known as marijuana) for people with psoriatic disease.
Shiva: Welcome Dr. Hawkes! It’s such a pleasure having you back today! To begin our discussion, let’s talk about how the landscape of cannabis-based products has changed since you first spoke about CBD on Psound Bytes™ in episode 90. At that time there were 11 states in the US where cannabis or marijuana use was fully illegal. It seems like the legality of use has changed along with an explosion of cannabis-based products. What’s your opinion on the reason for this expansion?
Dr. Hawkes: Yeah, it's a great question. There's been a big expansion in this cannabis-based industry and part of that has been patients interest in novel treatments for conditions like pain or itching or arthritis conditions, and we haven't seen a lot of new developments and advances here. And there's also been a secondary push for patients to avoid traditional medications and maybe seek out more “natural” therapies. So, we've started to see this change across the U.S. and it's shifted from recreational use into more medical use as a science has started to improve around what these cannabis-based products do in the biology. We're starting to understand what the biology of THC versus CBD, for example, what they do on the body, how they affect specific tissues or even certain cell types. And as they relate to different medical conditions. So, patients are asking questions, could this area or these specific type products be beneficial? There's also been a push from the commercial side. This is obviously a profitable industry and we've seen the commercialization of cannabis-based products really move quickly here in the U.S. and that includes businesses that are even active on Wall Street. So, when we think about the expansion, obviously that comes with a lot of complexities and we start to dive into what does that look like from a legislative landscape and how do we approach this from the state level and also at the federal level. What's really interesting is that when we did this first episode it was in September 2020 there were about 11 states where cannabis-based products were fully illegal, but now today this is always a moving target. But today there's four states, only four states in which it's fully illegal. So Idaho, Wyoming, Kansas, South Carolina. So there's clearly a large interest in this area, and this has been driven from both businesses, clinicians and patients.
Shiva: Thank you for sharing your opinion on that. So do you feel the use of cannabis-based products will continue to grow?
Dr. Hawkes: The data seems to support that. We're definitely having more conversations around cannabis-based products, you find them in stores, more often we're seeing them in driving down the Interstate, in billboards, social media. So I think there's a continued trend is that these are very popular products. I have patients that ask on a regular basis or in a regular week I'll have multiple inquiries. Whereas 5-10 years ago it was maybe a taboo topic or not discussed openly in the medical field. So, part of that is more general acceptance of these types of products, less stigma around them, so they're starting to come into mainstream activities, including medicine.
Shiva: So you mentioned earlier that many in the psoriatic disease community are looking for adjunct or nontraditional therapies to aid in pain management. What's the active ingredient in cannabis responsible for reducing pain? And is this a viable alternative worth exploring further?
Dr. Hawkes: Yeah, there's a lot of layers to that question. The first layer we have to take on is a larger discussion as to what type of product. So, there's a big difference between recreational or you know medical grade or synthetic products that are coming into the market. So, we really have to make sure we're speaking clearly about the particular products and when we have that conversation, we define exactly synthetic or natural, or are we talking about THC or CBD. These are two of the main active ingredients in the cannabis plant and also those that are being synthesized and created in laboratories. We start to talk about a specific molecule and what's its effect on the body. And again, lots of layers to this. So, we have the endogenous cannabinoid system (the endocannabinoid system) which is inside of our body and obviously derivatives can of these products can interact with that built in system. And so what we're starting to tease out in the science of this field is how do specific products, for example, those that are THC based versus those that are CBD based, how do they impact the body and how do they impact a specific disease or aspects of biology? So we think of THC as the traditionally psychoactive agent, whereas CBD is traditionally the non-psychoactive component that's really more aligned with pain management and I think traditionally more of the medical symptoms that are often described pain, itching, as you mentioned. So we're starting to understand which of these molecules have specific benefits for specific circumstances. There's also another layer to this, which is whether the receptor for these chemicals are peripheral, so further away from the body or central like our nervous system. So obviously the effect that we're seeking in using these various products may or may not be beneficial or may have other side effects that need to be considered and there's a lot of science going into developing these products that could maybe be more restricted to peripheral action versus central action or both. And when we think about pain in particular, most of the pain signaling appears to be mediated by the CB1 or the CBD related receptor versus the CB2 receptor. And so there's been a lot of interest in that area, but we also have to consider the effects of these receptors as they exist on other tissues. So, for example, the heart. So, you may be using this for pain, for example, but your heart tissue is responding to those chemicals because those tissues have receptors. So, we need to consider what I would sort of categorize as off target effects. Their effects that impact other parts of our body or our biology that maybe wasn't the intended use. So, part of the science and the clinical studies need to tease that piece out so that we can have more informed conversations with our patients as to what would be the potential advantages or potential side effects or drawbacks of using these particular products.
Shiva: That's a great segue into our next question. Traditional pain relief therapies can have side effects that can cause liver toxicity, gastrointestinal bleeding and kidney problems. Opioids are habit forming and may result in adverse events. How effective is cannabis in comparison and are the side effects better or worse? You mentioned earlier the impact on the heart.
Dr. Hawkes: Yeah, this is a challenging question because it's not quite that simple. Pain, it's quite complex. So the type of pain that individuals experience really needs to be teased out. For example, pain from skin condition may differ from pain related to a joint or bone source, cancer pain, nerve pain. These are different types of conditions that often get lumped together under this category of pain, but not all pain is equal and likewise not all pain responds to the same therapy. So, bottom line is that we don't have the data to really answer a lot of these questions. What we do know is that comorbidities of a particular patient may limit use of a particular agent. For example, patients who have chronic constipation, opioids are not a good option because we know that long term use of opioids can exacerbate those conditions. So what we have to take is a specific situation or a clinical indication. We have to look at our patients and then consider are there reasons why particular agents should be avoided? And one of the advantages to opioids, for example, is that they may not be prone to some of the same complications that we see with non-steroidal anti-inflammatories such as the kidney problems or bleeding or some of the habit-forming aspects of opioids. But that's really to be determined, and these particular studies are going to help us tease that out. And I think as we also look at the use of these therapies, we also have to consider whether we're using it as a monotherapy, meaning it's the only treatment. So, say for example, psoriatic arthritis, are we comparing only anti-inflammatories compared to only opioids? Or, are we talking about potentially adjunctive therapies where we add cannabis-based products to pre-existing therapies? So that's a little nuance, but it's important because it may be that incomplete control of a particular symptom or condition like psoriatic arthritis in addition of cannabis may actually improve symptom control without adding a lot of side effects. So, these are the types of studies that are needed and we have learned from some of the initial opioid studies of clinical trials particularly for pain we did see some of these side effects that limited their use. For example some patients did have cardio toxicity. We saw a worsening of metabolic syndrome, for example, diabetes, blood sugar. So, these effects need to be considered as we have conversations with patients about whether cannabis derived products would be appropriate for them. So, we really wanna head towards that direction of personalized medicine rather than one size fits all medicine.
Shiva: So, I'm curious is the FDA starting to regulate use of cannabis-based products?
Dr. Hawkes: Definitely, we're seeing as the popularity of cannabis-based products continues to grow and more specifically become commercialized then the FDA has an obvious role there because central to their mission is keeping consumers healthy and safe. When there's opportunities to make money, there's certainly opportunities for companies to get a product out there. There may be unsubstantiated medical claims or false claims about products or lack of transparency. There may be safety concerns around how these products are delivered or manufactured. So, just like any over-the-counter product or things that consumers can purchase, we wanna have some regulation primarily from the standpoint of safety, not to limit the industry necessarily, but to make sure that what is available comes with appropriate warnings, transparent information that it's been vetted in terms of safety. And so, these are efforts that are definitely ongoing and I think we'll appropriately see regulations to ensure that both providers and also consumers are protected and safe and obviously that will happen in a different way for over-the-counter versus prescription-based products. But appropriately so we're seeing more involvement from these regulatory agencies.
Shiva: It’s so good to hear. So, this discussion actually brings us to the results of a survey completed by the NPF Medical Board. How did this survey by the medical board occur?
Dr. Hawkes: Well, in my collaboration with Dr. Adam Friedman in George Washington University, we came up with this idea of surveying the medical board. The medical board representing a wide variety of expertise in the management of psoriatic disease, including skin disease and psoriatic arthritis also includes both dermatologists and rheumatologists. So the idea was patients were asking a lot of questions about these products. Cannabis derived products, are they safe? Will they be beneficial? Can I use them? Can they be used in combination with the other therapies? And this isn't a topic that has been traditionally approached in medical curriculum or even training programs such as residency. So, what we really wanted to evaluate was how familiar were these leading experts in psoriasis and psoriatic arthritis. What was their familiarity and understanding of these cannabis derived products and were they seeing a need for increased education on the topic and what was the perception that they were sort of getting from their patients? Were they showing interest, were they asking, have they ever prescribed it? So, it’s really just a pulse check as to how the National Psoriasis Foundation's Medical Board viewed this topic and what they're understanding was of it and if they felt like more education in this area was appropriate. So, it was really a survey of the current climate.
Shiva: You’ve already alluded to this but what are some of the reasons health care providers who completed this survey indicated they would consider use of a cannabis-based product for their patients?
Dr. Hawkes: Yeah, part of what came out of the survey was there was clearly an increase in inquiry from our patients and providers had some understanding, but not the same understanding that we would have say in the pathogenesis of psoriasis for example. So, the bottom line was there was clear indication that education was lacking. The medical board was interested and patients were either using and or asking questions about cannabis-based products. And most of the medical board that responded saw the indication for potentially prescribing these medications or recommending recreational use primarily for inflammatory conditions. Probably a lot of that was pain or itching, for example psoriatic arthritis pain as I mentioned. And then also some of the psychosocial aspects of inflammatory disease like anxiety, depression, trouble sleeping. So, these were all possible areas or symptoms or circumstances in which some of these experts might consider that or might encourage patients to seek out some of these cannabis derived products. I think this is also based largely on patient preference or request. That's one thing we'll have to tease out from future studies and surveys is are patients more likely to use these products because their healthcare provider was recommending them? Or is it more so that the patients are requesting information they're showing interest or they’re asking to use these in sort of getting confirmation or affirmation from their health care providers it's OK to use them. But most of the survey respondents indicated that they would consider their use primarily based in this belief that it might have a therapeutic benefit. So it might help to control their disease or add additional disease control on top of existing therapies.
Shiva: So, you mentioned perception of use. Through this survey, was there enough evidence to suggest that cannabis-based products may offer therapeutic benefit for people with dermatological conditions such as psoriasis or atopic dermatitis?
Dr. Hawkes: Yeah, this is an important distinction to make here. The type of survey we performed isn't the type of research that would lead to direct evidence, right? We can't say because of our survey we know this is going to be beneficial or effective. The evidence that will support the use of these products in certain conditions like psoriasis or atopic dermatitis is going to have to come from specific studies that are evaluating these patients such as clinical trials where we're specifically measuring the potential therapeutic benefit and or side effects in these patients specifically. And we don't have those studies right now. There’s been a lot of interest, they’re necessary, but right now to my knowledge we don't have any psoriasis dedicated studies to really answer those questions or to give us grounds to say this definitely works. We want to understand that and that's something I hope will happen so that we can start to inform patients and help them see that from such and such clinical trial patients who use these products experienced this benefit or we might see the other they didn't experience benefit in their symptoms but there were side effects that you need to be aware of. So we're going to need those studies and until we have those studies, we really can't say anything definitive, but the interest is there, there's opportunities and having these types of studies are going to establish a precedent that will give us more definitive information to make recommendations or to suggest which patients should or should not be using these products. Ultimately, what we hope to have is more and more weapons in our armamentarium for treatment because our real goal is to have multiple options so that we can best alleviate the burden of disease and suffering in our patients, particularly those with psoriatic disease. Whether or not these products will help, it's not entirely clear. But I'm hoping we move in that direction so we can start to answer those specific questions.
Shiva: And Dr. Hawkes, as part of this survey by the medical board, they referenced a study published in the Journal of Drugs in Dermatology in which 17.6% of 504 people surveyed reported use of an over-the-counter cannabis-based personal care product without the recommendation of a dermatologist to treat their dermatological condition. Is this a recommended practice? And what are some of the concerns that they should be considered by use of OTC cannabis-based products?
Dr. Hawkes: Yeah, this is an important point as well. I think most of the use that we probably encounter in medicine is going to be patients using it when our health care provider has not recommended it. That's primarily because most of the cannabis-based products are for recreational use. There really are very few dermatologic conditions, in which these cannabis products are approved. I think since 2016 Connecticut's been the only state to specifically list psoriasis and psoriatic arthritis as a qualifying condition for medical cannabis use. Though they're like 7 states that list arthritis as a qualifying condition like Arkansas, California, Connecticut, Hawaii, Illinois, New Mexico and New York. So because of that the vast majority of conditions as it relates to psoriasis are not going to be medical symptoms or conditions that they could get medical cannabis-based products for it. So again, I think most of our interactions with patients are going to be these sorts of non-medical recommended therapies. And that's important because our patients are using them whether or not we’re recommending them. And that's a really important point. It's not a question of when they come. They're here. And so we need to be educated as to their potential benefits and or side effects. So the real problem with this type of use is mostly centered in safety. So it's gonna be really central to this issue is that we want patients to have improved symptoms, better disease control, but we also don't want them on therapies that can worsen their disease or help with one thing while making another problem worse in the body. Because there's so much variation in the manufacturing, the packaging, the lack of transparency around active ingredients in these over-the-counter or commercial products. There's unsubstantiated medical claims or scientific claims that may not be based on good science. These are all issues that create a murky industry and I think it makes it very challenging for patients to approach these types of products. Mode of delivery, meaning is it smoked, is it delivered topically? Is it a patch? Is it sublingual? All of these different modalities impact how the drug affects the body and that's gonna be an important thing to start teasing out so that we have familiarity with pros and cons of these different delivery mechanisms so that we can start to have these more informed open conversations. So the benefits are one aspect but the potential risks are the other aspect. And patients just have to know that they're taking a risk anytime they use something that's not recommended by their physician. And again, this isn't a one size fits all. So, in some patients these products may be perfectly safe, but there are other situations where they may be contraindicated or should be avoided. For example, patients with diabetes or metabolic syndrome, cardiovascular disease, how do we regulate these products or how would they impact people who are operating vehicles or machines, bus drivers, people commuting to work. We gotta think about the pediatric population versus adults versus our elderly population. Women who may be trying to have children. There's a whole number of factors where just the blanket use of these as being safe or you don't need your doctor’s approval or recommendation or have a discussion comes with an inherent risk. So patients just need to be aware of that.
Shiva: That's a good point. So basically, proceed with caution.
Dr. Hawkes: Right.
Shiva: And what do you anticipate will be the potential outcomes of the survey presented by the medical board?
Dr. Hawkes: The effort was mostly about raising awareness, assessing interest, advocating for ongoing efforts and research in this area to explore the potential benefits or risks of use of cannabis-based products in psoriatic disease patients. I don't know that it will necessarily lead to a particular outcome, but if anything, it gets some of our experts thinking and talking about a topic that really hasn't been adequately addressed in our traditional medical system or education curriculum. The National Psoriasis Foundation, wants to continue to lead and be at the forefront or ahead of the curve on some of these topics. So, we're showing our patients that we're listening, we're hearing their inquiries and their interest in this topic as well as the desire to have more specific education and to potentially participate and partner with us, in starting to study these particular topics. So, I'm hoping this at least helps get this topic on the map for patients who are impacted by all of the aspects of psoriatic disease on their life and getting these experts in the room with those patients, having these conversations is really what we hope to do because it's about alleviating disease burden and also keeping our patients safe and healthy.
Shiva: I whole heartedly agree. So what's the message for people with psoriasis and psoriatic arthritis?
Dr. Hawkes: I would encourage our patients to have open and honest conversations with your dermatologist or your rheumatologist who manages your psoriatic arthritis about potential use of cannabis-based products. That may also be just a discussion about your thoughts about cannabis derived products or your interest in exploring these products for your condition are also some of the symptoms, such as anxiety, trouble sleeping, itching, pain. These are all things that we want our patients to be open about and I think having the conversation doesn't necessarily commit you to using these products. But at least you're being open with your provider so that we can start to partner with you and have more transparency about things that you're doing. I worry about patients who are using these products and not telling us, because if there are negative impacts to other disease, we may not be aware of that and we wanna definitely have the full picture so that we're making informed decisions as well as patients we want to share information so that they're also making informed decisions. So, it's a two-way street and having the openness to honestly discuss what patients are doing at home is a good idea. And, I think they'll find their providers are more open to this topic than maybe they would have previously thought.
Shiva: Yes, shared decision making is so important and we encourage our patients to have those needed conversations. Dr. Hawkes, do you have any final comments you’d like to share with our listeners?
Dr. Hawkes: Yeah, a few points. One, I really want patients as they're considering the use of cannabis-based products to not ignore what's already known about psoriatic arthritis and also the other variants of psoriasis like plaque psoriasis. What’s central to all of the variants of psoriasis is that we have a dysregulated immune response, meaning that our immune system is overactive. We've started to tease out some of the specific signals that are elevated in our skin and our joints that are driving this disease. For example, interleukin-17 and interleukin-23. We have drugs that can block those signals and what I don't want patients to walk away from these conversations is this idea that cannabis derived products alone are going to be sufficient to control the immune response of their psoriasis. Partly because we really don't know how effective these cannabis-based products are in regulating that overactive immune response. So, it may be that rather than replacing existing therapies such as the topical steroids or biologic therapies that our patients are quite familiar with. It may be that these cannabis derived products are really to be used as adjuvants or conjunctive therapies. For example, patients who are doing really well in managing their skin disease, but they're still having some persistent pain. That might be an opportunity to add to the therapy. And so, it's really important to not let the excitement of an up-and-coming area sort of overshadow or minimize what we have already established clearly, which is that the best results in managing psoriatic disease is really calming down that overactive immune response. So, anything that these products do are going to be attacking that immune aspect, it maybe that the comorbidities of psoriasis, again the anxiety, the itching, the pain are going to be the primary role for these cannabis derived products.
Shiva: Thank you, Dr. Hawkes, for being here and providing this update about the use of cannabis-based products and the survey results from the NPF Medical Board. For our listeners, if you’re experiencing chronic pain, please contact the National Psoriasis Foundation’s Patient Navigation Center to receive the Chronic Pain Kit which includes a pain management guide and tracker, along with tips for discussing chronic pain with your health care provider. To request your free kit today call (800) 723-9166 or email email@example.com.
We hope you enjoyed this episode of Psound Bytes™ for people with psoriasis and psoriatic arthritis. If you or someone you love has ever struggled with psoriatic disease, our hope is that through this series you’ll gain information to help you lead a healthier life and inspire you to look to the future. Please join us for another inspiring podcast. You can find this or all future episodes of Psound Bytes™ on Apple Podcasts, Spotify, iHeart Radio, Google Play, Gaana, and the National Psoriasis Foundation web page. To learn more about this topic or others please visit psoriasis.org or contact us with your questions or comments by email at firstname.lastname@example.org.
This transcript has been created by a computer and edited by an NPF Volunteer.
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