So, does CBD's reputation prove true?
We wanted to understand where the research stood on CBD – its potential benefits as well any concerns, its promise as well as its limitations. So we contacted Jenny Wilkerson PhD, Assistant Professor of Pharmacodynamics at the University of Florida and co-author of the article "CBD: Rising star or popular fad?" for The Conversation, and we asked her a few questions.
Dr. Jenny: Marijuana and hemp are different strains of the plant Cannabis sativa. Marijuana can also come from the plant Cannabis indica. However, hemp is fully legal to possess and grow in the United States, while marijuana is the strain that is in different stages of state legalization/ decriminalization but is still fully illegal federally.
These strains of Cannabis sativa (often referred to as just Cannabis) are essentially the same, but they have some subtle differences. The main difference is the amount of Delta-9-Tetrahydrocannabinol or THC each plant contains.
THC is the compound that exists in all strains of Cannabis that gets people high. While marijuana can contain upwards of 10-40% THC, hemp contains 0.3% or less.
Cannabidiol, or CBD, is also found in all strains of Cannabis but does not get people high. In the laboratory, both THC and CBD have shown promise to produce therapeutic effects, including relief from some aspects of pain.
Dr. Jenny: The United States is in the midst of an opioid abuse and misuse epidemic. This statistic is a bit old, with data collected from 2000-2013, but approximately 80% of all new heroin users get their start from misusing prescription opioids.
This has brought into sharp focus the science behind opioid use for pain. Although many patients are prescribed opioids for chronic pain, the evidence is resoundingly clear that opioids are not very effective for long-term, chronic pain control.
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This factor, coupled with the desire not to repeat history with developing analgesics, or pain-relieving drugs, that have such a strong abuse potential as opioids, has led to an urgent need to develop non-addictive therapeutics for chronic pain.
In addition to reports that CBD does not get people high, laboratory studies which are routinely used to screen drugs for their abuse liability show that CBD does not possess a strong abuse potential. In fact, some studies have shown that CBD may be a good treatment for drug addiction, including opioid addiction.
Dr. Jenny: We know a lot about the serotonin receptor, one of the receptors in the body that seems to produce most of the functional effects of CBD. This is where a lot of the hype over CBD stems from – the thought that it might be the next ‘cure all’ for several hard-to-manage issues that so many people deal with.
However, we do not know enough about exactly how CBD works with the serotonin receptor. Because different physiological outcomes (i.e., regulation of sleep, mood, anxiety, and pain) are regulated through different actions at the serotonin receptor, we don’t know enough to make strong predictions of exactly how well CBD will produce a therapeutic effect in these outcomes.
To complicate matters, most scientific studies, up until recently, have predominately used male subjects for research. This is changing, due to new National Institutes of Health rules. However, If women are used, they are generally not in perimenopause or menopause because it has been well documented that the associated hormonal changes can alter how some drugs work. So, until we know how CBD will work specifically in perimenopausal and menopausal women, it is hard to draw direct conclusions from what is seen in men.
Although there are plenty of possibilities that CBD may produce at least a subset of these therapeutic effects, we don’t yet have solid evidence of which ones. Indeed, it would be wonderful if it turns out that CBD really works for more of these outcomes, rather than fewer.
Dr. Jenny: CBD is currently only prescribed as the drug Epidiolex, for the treatment of intractable pediatric epilepsy.
In order for a physician to be able to prescribe a drug, it has to fulfill several important criteria. One of these initial criteria is that it has to be proven safe. Epidiolex did this, and so this is why pharmaceutical-grade or very pure CBD is generally regarded as ‘safe.’
However, another main criteria that has to be met by potential drugs is that it has to be proven to work as well, or better than the current drugs on the market. This is very important and has to be done in what is known as a ‘double-blind, placebo-controlled’ study.
We know that the placebo effect is very real, and that when people even have the idea that they will get relief from pain, they report feeling less pain. This occurs even when people get a treatment where there is nothing present that would biologically cause pain relief. So, the patient can’t know if they get the drug or placebo, and the person giving them the treatment can’t know either, because we know this can alter perceptions as well.
Because CBD has only been rigorously tested in this manner for seizure control in intractable pediatric epilepsy patients, we don’t know if it will stand up to this test for regulating pain, sleep, mood and anxiety.
Another concern I have about casual use of CBD is that although pharmaceutical grade CBD was deemed safe by itself in the Epidiolex clinical trials, they found that it can interact with other drugs, such as the drug valoproate which may be prescribed for seizure activity, migraines, and bipolar disorder.
Thus, it is likely that CBD may interact with other drugs as well. This could mean taking CBD with certain drugs could diminish or enhance the effects of prescriptions, leading to problems controlling particular medical conditions that were once well-managed, or increased side effects of the other medications.
For this reason, it is incredibly important to talk to your doctor or pharmacist about potential drug interactions with other drugs before taking/trying CBD.
Dr. Jenny: This is a bit of a concern for me. Only Epidiolex is approved for a medical condition and undergoes Food and Drug Administration (FDA) regulation. All other forms of CBD aren't regulated, so there is no real way to know what you are spending your money on.
There have been numerous consumer reports that show that the actual amount of CBD that is in the over-the-counter products is significantly less than what is reported on the label. Also, some of these over-the-counter products contain enough THC to show up on drug tests.
Therefore, using the CBD that's out there for a serious medical condition is going to be tough, because you don't really know how much or even exactly what you are getting. If you don't see an effect with CBD, it could be that you aren’t getting the correct dose, or it could be that CBD isn't going to work. If using CBD from the shelf doesn't work, it might be difficult to know when to cut your losses and put your time, effort, and money towards other avenues.
Because of those reasons, even in pro-medical CBD/ marijuana states, most physicians are very hesitant to prescribe CBD. Additionally, in the future, if CBD is developed as a therapeutic for a given condition, if someone has already tried an over-the-counter CBD product that didn’t work, they might be less likely to use CBD where it could work.
Dr. Jenny: I cannot recommend the purchase of over-the-counter CBD, for the above reasons. I recommend that if you want to try CBD, be smart and informed. Look up reports from third-party groups like consumer reports, to get an idea of what you might actually be purchasing with your hard-earned money, keeping in mind that these reports can change from one batch to another.
Dr. Jenny: As a chronic pain and drug abuse scientist, I am very interested in on-going research into the potential of CBD to produce pain relief and reduce the over-reliance of prescribing opioids for chronic pain, as well as a treatment for opioid abuse and addiction.
More about Dr. Jenny Wilkerson: Jenny Wilkerson joined the University of Florida College of Pharmacy in November 2017 as a research assistant professor in the Department of Pharmacodynamics. Prior to joining the University of Florida, she was a postdoctoral fellow at Virginia Commonwealth University in the Department of Pharmacology and Toxicology where she received the competitive Ruth L. Kirschstein F32 Individual National Research Service Award from the National Institute on Drug Abuse. She received her Ph.D. from the University of New Mexico in the Department of Neuroscience.
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