Ask a Doctor: What Are the Health Benefits of CBD?
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Cannabidiol (CBD) has seen an explosive surge of innovative products and public interest in the last decade. CBD is marketed everywhere from teas and lotions to pet products. Consumers frequently look to physicians for guidance and recommendations on CBD usage for various medical ailments. Medicines today are expected to be of known composition and quality. But currently, most CBD products do not meet this expectation as there remains a lot to learn about the indications and use of CBD.
CBD is a natural component of the plant Cannabis sativa. There are over 500 chemical substances naturally occurring in Cannabis sativa and over 100 of those are cannabinoids. CBD and Tetrahydrocannabinol (THC) are the most well-known cannabinoids. THC is the primary psychoactive component of cannabis; conversely, CBD does not cause any intoxication or high in the user.
Cannabis-derived compounds are extracted directly from cannabis plants to create drug products, while synthetic cannabinoid-related compounds are created in the laboratory.
CBD: Health and Politics
Medical cannabis, used to treat conditions ranging from anxiety to glaucoma, contains cannabinoids with greater than 0.3 percent concentration of psychoactive THC. Conversely, CBD products are extracted from hemp, a specific variety of Cannabis sativa that contains less than 0.3 percent THC.
While medical cannabis is commonly smoked or consumed orally, CBD comes in many forms, including oils, sprays, and food. If the percentage of THC is less than 0.3 percent, then it is entirely legal to create and market CBD products.
On December 20, 2018, President Donald Trump signed the Agricultural Improvement Act of 2018, known as the “2018 Farm Bill.” The bill removed hemp and cannabis derivatives with extremely low concentrations of THC from the Controlled Substances Act (CSA), making these products legal. While legalizing certain variations of hemp and cannabis derivatives, the Farm Bill also increased the regulation of hemp production under the U.S. Department of Agriculture (USDA).
Additionally, the Federal Drug Association (FDA) remains heavily involved in monitoring the science, safety, and quality of products containing cannabis and cannabis-derived compounds, particularly CBD. The FDA is a governing body that protects consumer health and requires studies and evidence to maintain vigilance over drug products. The FDA approval process ensures the efficacy, safety, and quality of a medicine before use by the general public.
FDA-approved medicines are available by prescription in pharmacies, whereas most cannabinoid products that have not undergone the FDA approval process are sold in dispensaries and online. Many non-approved CBD products are marketed as having the ability to treat a wide spectrum of diseases and symptoms. Thus, CBD has garnered widespread interest as a panacea for various ailments and health issues.
The FDA, however, has expressed concern over the number of CBD products being marketed with claims of therapeutic benefit that remain unsubstantiated. While CBD has shown promise in treating some disease-related symptoms, there is still a lack of data to support many of the claims. The FDA has previously sent warning letters to companies illegally selling unapproved CBD products that claimed to prevent, diagnose, mitigate, treat or cure various diseases. Additionally, THC or CBD products cannot be sold as dietary supplements or added to food for humans or animals under the Federal Food, Drug, and Cosmetic Act.
Medicinal Use of CBD
To date, there is only one FDA-approved pharmaceutical use of CBD. Epidiolex is the first cannabis-derived medicine approved by the FDA. It has been shown to reduce and sometimes completely stop seizures in pediatric patients with disorders such as Dravet syndrome and Lennox-Gastaut syndrome (LGS)—a group of seizure disorders that start in childhood and involve frequent seizures along with severe cognitive impairments.
Epidiolex is a plant-derived CBD-only product, with no THC. Using the non-psychoactive component of CBD allows patients to have few psychoactive side effects while still having the benefit of reduction in seizure frequency.
While Epidiolex is the first cannabis-derived medication, there are FDA-approved synthetic cannabis-related drug products: The medications Marinol (dronabinol), Syndros (dronabinol), and Cesamet (nabilone) have been on the market for a long time and are used in adults to treat chemotherapy-induced nausea, vomiting, decreased appetite, and weight loss in patients with AIDS. Because of the THC content in these medications, there tend to be significant side effects (e.g., dizziness, sedation, confusion) that affect the ability of patients to tolerate them, often leading patients to stop using the medication. People taking cannabis-based medicines were more likely than those taking placebos to drop out of studies because of these side effects.
Additionally, other countries make use of THC:CBD combination medications. For example, the United Kingdom has approved Sativex, a combination medicinal cannabis extract that contains 1:1 CBD and THC. Sativex is used as an oral spray for symptoms related to multiple sclerosis and severe neuropathic-related cancer pain.
And while studies have shown some efficacy when using THC:CBD combination medications for neuropathic pain, it is difficult to definitely attribute the therapeutic properties to CBD alone. In these combination medications, CBD is always administered with THC, and there is no specific high-quality evidence in humans that CBD alone helps with pain management. However, when the two compounds THC and CBD are co-administered, CBD works as an antagonist to counteract certain effects of THC. Thus, CBD can help to reduce side effects, including tachycardia and altered cognition, when used in combination medications.
Pharmaceutical companies are expanding their research efforts in cannabinoid therapies to offer high-quality products with known safety and efficacy. There are many products undergoing clinical trials and most of the products in the pipeline are synthetic CBD analogs, including several studies examining topical synthetic CBD for the treatment of serious skin diseases.
Another synthetic CBD in preclinical trials has been reported to have the potential for anti-depressant and anti-anxiety effects far beyond what has been achieved with plant-derived CBD. There are also combination medications actively being researched for use in various diagnoses from obstructive sleep apnea to spasticity and agitation.
CBD and Pain
In the market, CBD is often touted as the miracle treatment for pain. However, there are no approved pharmaceutical products that contain CBD alone for the management of pain.
Reviews of the literature have revealed that the evidence shows small benefits of limited value in patients taking cannabis or cannabinoids for chronic pain. And these studies are not focused on CBD-only products.
The strongest scientific evidence to date of CBD alone comes from animal studies. Research identifies how CBD may inhibit inflammatory and neuropathic pain, two sources of pain notoriously difficult to treat. A 2016 study revealed that transdermal CBD gel significantly reduced joint swelling and scores of inflammation and pain in animal subjects. The higher the dose of CBD gel used, the greater the reduction in inflammation, suggesting a direct correlation.
While these studies show promise, there still needs to be high-quality scientific evidence in humans. And until that exists, it is difficult to recommend regular use of CBD in chronic pain management.
The Safety of CBD
The lack of standardization amongst CBD products creates challenges for physicians and consumers. Patients often ask for guidance on administering CBD; however, the variety in production and formulation makes it hard for clinicians to provide recommendations on use. It comes in different strengths and forms including oils, capsules, lotions, and powders. It can be absorbed through the skin, ingested, or inhaled. Beyond the FDA-approved formulation, we don’t know the most effective therapeutic dose of CBD for any particular medical condition.
Currently, it is illegal to market CBD as a supplement or food product. Some CBD products are marketed with unproven medical claims and are of questionable quality. The FDA has taken disciplinary action against companies illegally selling CBD products that are claimed to prevent, diagnose, treat, or cure serious diseases, such as cancer.
Additionally, the FDA periodically tests products to measure the content of cannabinoid compounds and have found that some companies misrepresent the dosages of active cannabinoid. When tested, some products have CBD content inconsistent with what is listed on the label.
While it is mostly well tolerated, CBD is not without potential side effects. Side effects may include changes in alertness, drowsiness, diarrhea or decreased appetite, and mood changes such as irritability and agitation. People taking high doses of CBD may show evidence of liver injury. Moreover, CBD can affect how drugs are metabolized by the liver and thus alter the potency and effectiveness of other medications. There is an increased risk of sedation and drowsiness when CBD is taken with alcohol or other drugs that affect brain activity to treat anxiety, panic, stress, or sleep disorders. There are even reports of male reproductive toxicity in studies of animals exposed to CBD.
The FDA is actively working to learn more about the safety of CBD products. Aside from the risks identified above, the FDA continues to evaluate the risks of cumulative exposure and the effects of CBD on special populations including the elderly, children, adolescents, pregnant and lactating women, and animals.