Like any supplement or product being consumed and used, it is wise to do your own research to make informed and safe choices.

There are eight medical conditions for which patients can use cannabis CBD -- cancer, glaucoma, HIV/AIDS, muscle spasms, seizures, severe pain, severe nausea and cachexia or dramatic weight loss and muscle atrophy. CBD is being used as part of performance and recovery routines for athletes as CBD helps with inflammation too.

Other uses are not endorsed by the medical community but continue to be used based on anecdotal stories from people who have either received relief or improvement from CBD products. Unfortunately, the general population interested in these products are more interested in the promise of hope for relief, than they are for the real scientific studies and proof.

CBD Products

Just as olives can create a variety of products such as the whole eaten fruit to different qualities of olive oil ranging from heat-extracted, to cold-pressed, and virgin, so do CBD products vary. Because of the explosion of products, consumers largely don’t really know what they’re buying and the percentage of THC in the product. Many products don’t fully disclose their ingredients.

In 2008 the FDA sent warning letters to eight companies producing CBD products announcing that they either had no or barely any CBD, or that some contained illegal THC that contaminated the product with potential psychoactive properties. There is no regulation of these products, which can make them dangerous for someone’s health, or pocketbook by wasting money on a useless product. A later study in 2017 examined 84 CBD products purchased online and found that almost 70% were mislabeled (Penn Medicine News, 2017). Without regulation, CBD companies are policing themselves but can have wide fluctuations within their own products even in the same package.

Hemp seed oil has been used for bath oil, lamp oil, cooking oil, and a main ingredient in the food and supplement products being seen in the market today. The hemp seed oil is extracted by pressing the actual hemp seeds from the plant. It is rich in omega-6 an omega-3 essential fatty acids and a key in the claims and use for topical and ingestible products for skin and healthy tissue.

Because of the essential fatty acids, hemp seed oil was studied in 2005 by a physician in Finland for successful treatment of atopic dermatitis, known as eczema. A reduction in dryness, itching and overall skin improvement was found (Callaway, 2005).

Routes for CBD Delivery

The route of delivery of CBD impacts its bioavailability as oral intake of the drug is only 6% available in humans compared to 11% to 45% via inhalation (Scuderi et al., 2009). This may explain why for decades smoking marijuana has been the preferred route by recreational users.  It is fat soluble and only soluble in organic solvents, which manufacturers create. Because it is lipid soluble, it can remain in the fat tissues and must be metabolized by the liver’s first-pass effect. Therefore, the effect of CBD can be slow compared to an inhaled version, such as an infuse or nebulizer.

CBD doesn’t appear to have psychotropic effects but conversely does show positive effects against anxiety and even PTSD (Iseger & Bossong, 2015). Medical marijuana however, does still product psychoactive effects and just because it has the name medical does not imply it is safe and without side effects.

CBD can be manufactured in oils, drops, tinctures, vaporized pens, creams, syrups, oils, lip balm, soaps, massage oils, shampoo, and foods such as gummies, drinks, and even pet foods. It may be delivered via several routes including inhalation by smoke, (vapor or aerosol spray), or buccal into the cheek, sublingual, and oral routes. It can be delivered topically such as in creams, lotions, ointments, and shampoos.

A huge concern is that the CBD products are not regulated, standardized, or certified, and so results are varied. Brands that are more reliable are difficult to determine and so consumers must be informed and do their own careful research. Unfortunately, usually the publicized and online information is originated from the manufacturers or product marketing departments themselves and not disinterested third parties using scientifically based studies.

Here are some products derived from hemp plants:

Hemp used for food products have exploded to over 25,000 products in the past few years and those with CBD were introduced in 2017 (Price, 2015). Consumers must be very wary of products claiming they contain CBD as many have been found to be false. Consumers can look up cannabidiol related product reviews on the FDA website since 2015, and even read the warning letters given to these manufacturers for false claims. People are wasting money and possibly worse with unintended side effects. Beginning in October 2019, the New York City Department of Health will fine restaurants that sell foods or drinks containing CBD (LaVito & Franck, 2019).

In July 2019, the FDA stated:

Selling unapproved products with unsubstantiated therapeutic claims—such as claims that CBD products can treat serious diseases and conditions—can put patients and consumers at risk by leading them to put off important medical care. Additionally, there are many unanswered questions about the science, safety, effectiveness, and quality of unapproved products containing CBD (USFDA, 2019).

Top Producers and Manufacturers

In the ever-increasing and profitable business of supplements, CBD products are exploding. Manufactures vary from those well-researched and produced with high quality and those that make false claims and promises. Following is a simple list (in alphabetical order) of the top-most popular producers and manufacturers based on social media subscribers and purchases:

• Akive, Apothecanna, Barlean’s, Bluebird Botanicals, CBD Live Natural, Charlotte’s Web, CBDistillery, CBDfx, CBDMD, CBD for life, CBD American Shaman, Colorado hemp honey, Corners Cannabis, Curaleaf.
• Elevate, Elixinol, Endoca, Flo Kana, Foria, Green Compass, Green Gorilla, Green Roads, Herbstrong, Hempmeds, HempWorx, Hippie Butter, Highland Pharms.
• Infinite CBD, Irwin Naturals, Joy Organics, Kannaway, Kat’s Naturals, KushyPunch, Koi CBD, Lazarus Naturals, Livlabs, Lord Jones, Medterra, Moon Mother Hemp Company, nhancedcbd, Plant Therapy.
• Additionally, there are CBD oil, Procana, PureKana, Pure Hemp Botanicals, RE Botanicals, Select, Steve’s Goods, Source Naturals, and Zilis.

Therapeutic Uses

Although CBD manufacturers claim many therapeutic uses, only those based on scientific studies demonstrating statistically significant benefits are legitimate. The Food and Drug Administration does randomly assess various products, but it is difficult for the consumer to know which ones are legitimate unless they go to the FDA website. Otherwise, it is left to the integrity of marketers and manufacturers to correctly educate the consuming public, which is tricky at best. The following list of uses have studies with documented therapeutic benefits for CBD.

• Anxiety and mood disorders
• Pain and inflammation
• Seizures and spasms

CBD appears to boost serotonin levels in the brain and may stimulate the production of new nerves in the hippocampus where emotions and mood evolve (Campos et al., 2013). A concern is that although preliminary studies show hopeful positive benefits, the CBD manufacturers market their products will full endorsement regardless of the truth that human studies have not been completed or are only anecdotal and not based on rigorous scientific evidence yet.

CBD has been shown in laboratory rodents (mice and rats) to reduce inflammation and neuropathic pain by suppressing the α3-glycine receptors, which sense pain in the nervous system (Xiong et al., 2012). In the quest to find better alternatives for chronic pain due to the opioid crisis and legitimate concerns about side effects, CBD has the potential to deliver relief without the addictive side effects and warrants additional study.

Seizure control has been researched and became the first approved indication for CBD by the FDA. CBD has also shown promising results in relaxation and improved sleep from insomnia (Babson et al., 2017). With the caveat that more longitudinal studies are needed to determine clinical implications, cannabidiol synthetics such as nabilone and dronabinol have shown short-term benefits for sleep apnea, daytime sleepiness, and even nightmares associated with PTSD.

CBD is known to modulate the transcription of over 1100 genes that reduce inflammation in our central nervous system by up-regulating GABA receptors, which helps antiinflammation. They likewise are known to down-regulate the neurotransmitter glutamate and inflammatory biochemicals. What is difficult to assess, however, is that there are over 350 different chemicals involved in the inflammatory response, so it is not entirely clear how CBD truly impacts this process.

One noted 2017 study concluded that selective cannabinoids provided a small benefit in chronic neuropathic pain (Meng et al., 2018). They also conclude that there is a need for well designed, large, random controlled trials to better assess dosage, duration and effects on physical and psychological function before recommendations and approval for human use could be made. It is currently legal by accredited organizations with federal approval to perform cannabis studies in the United States.

A Cochraine Library review and meta-analysis done in 2018 on the use of cannabis products concluded that, collectively, all cannabis-based medicine performed better than a placebo in reducing pain intensity, providing moderate pain relief, and improving sleep and psychological distress. They recognized that high-quality evidence was lacking in these studies (Philips et al., 2018). Additionally, when looking at all cannabis-based medicine products, they believed they were no better than placebos in the conditions improving health-related quality of life. People had dropped out of the studies due to side effects of cannabis including sleepiness, dizziness, and cognitive problems.

Safe Use of CBD

Even if cannabis or CBD have real benefits for clinical use, the unreliable studies and purely anecdotal reports and claims have clouded definitive decisions by the FDA to approve CBD for many health conditions. The CBD in cannabis does show observed benefits in reducing anxiety and even tremors in patients with multiple sclerosis (Wlliamson & Evans, 2000). Chemotherapy-induced emesis is also reduced by cannabinoids.

The side effects of the whole cannabis plant include the mind-altering effects from smoking and the resultant lung irritants, mind impairment, and driving dangers while under the influence, but these side effects are absent when pure CBD is used.

The National Academies of Sciences, Engineering, and Medicine (NASEM) in 2017 concluded that oral cannabinoids were as effective as antiemetics in adults with chemotherapy- induced nausea and vomiting, and that adults with chronic pain experienced significant pain relief, and that adults with multiple sclerosis–related spasticity reported improvement of symptoms (NASEM, 2017). Confusion arises when results are so varied, seemingly dependent on the quality of the studies and who is funding the studies.

Is cannabis a rational solution to the opioid crisis? Proponents state that it is an excellent, less addictive alternative that will not cause death. The Alternatives to Opioids acts of 2018 (Illinois and New York) permit any condition that could be treated with opioids as a qualifying condition for medical marijuana. Those against this rationale state that use of THC products is just exchanging one addictive medication for another.

A meta-analysis study in 2017 found that when THC products were used in combination with morphine, the desired relief could be achieved with 3.6 times lower dose than with morphine alone. Likewise, the dose of codeine administered in combination with delta-9-THC was 9.5 times lower than of codeine alone (Nielsen et al., 2017).

In states where medical cannabinoid use has been enacted, there has been a statistically lower opioid overdose mortality rates of 24.8 % lower compared to states without medical cannabis laws (Bachhuber et al., 2014).

Health Risks

Like any prescription medication, there are always risks and side effects that need to be considered to determine if the benefits outweigh the risks. The psychodynamic properties of THC are always a concern for products that come from the whole cannabis plant. Although CBD has been approved if it contains less than 0.3% THC component, not all products on the market disclose their full ingredients and consumers may be unaware of the additional components, which may impact side effects.

Common adverse effects from cannabis include anticholinergic effects of dry mouth, blurred vision, urinary retention, tachycardia, constipation, and hypertension. Other CNS effects include ataxia, cognitive dysfunction, and even hallucination with any THC components.

Risks for Specific Populations

Cannabis can have serious side effects for special populations, including children and teens, pregnant and lactating women, and elders, who are also at risk for polypharmacy. Because the quantity of CBD varies from producer to manufacturer to product, amounts that exceed safety or are toxic are unknown. There are no studies on using CBD during lactation but the whole cannabis plant is known to pass through breast milk. CBD has been used for hyperemesis gravidarum but is not officially prescribed by physicians due to the lack of safety guidelines. An edible brownie or cookie with CBD may be therapeutic for an adult; however, there are no studies to confirm or warn regarding safety consumption in children.

Teenagers who are exposed to edible CBD products in their own home may also unknowingly consume THC products, which has shown to increase antisocial behaviors and pose a safety risk. One reason cannabis continues to remain on the Schedule 1 drug list is the unexplored potential for psychotic behavior, which can be dangerous for children and elders. Finding wiling participants in research studies of infants, children, teens, and elders becomes challenging due to national research safety guidelines.

Another population at risk are those with mental illness, who may experience a worsening of their illness with cannabis products. Because cannabinoids with THC appear to affect the same internal reward system as alcohol, cocaine, and opioids, patients may also develop a dependence on cannabis with worsening irritability, anxiety, sleep disturbances, and food cravings.

Apply Your Knowledge

What guidance can you give a patient who is looking to buy a CBD cream to decrease pain or inflammation?