CANNABIDIOL (CBD) AND OTHER PHYTO-CANNABINOIDS: A DOCTOR’S ADVICE TO INQUIRING PATIENTS
There is a burst of public interest in the potential medical benefits of cannabis products. Many physicians are relatively unprepared for the onslaught of inquiries. There is also much confusion in the United States spawned by relatively schizoid laws pertaining to cannabis — with individual states conflicting with federal statute, as well as varying levels of controlled substance scheduling tiers. In the midst of these issues, where and to whom should patients go to get useful information and a reasonable plan of care? Naturally, they seek out their physicians for advice.
Below is a composite of patient questions that I often encounter (and that I imagine many other physicians encounter, as well), and the responses that I give.
“DOCTOR, WHAT’S THE DIFFERENCE BETWEEN MEDICAL MARIJUANA AND THE CBD PRODUCTS?”
When many people think of cannabis, they think of marijuana – yet the term “cannabis” is actually short for Cannabis sativa, a plant species that contains many varieties. Marijuana and hemp are just two of those varieties.
THC versus CBD
The Cannabis sativa plant contains many phytocannabinoid compounds. Two of the most well-studied compounds are tetrahydrocannabinol (THC) and cannabidiol (CBD). It is thought that both may have positive medical benefits. An important distinction between THC and CBD is that THC is inclined to produce euphoria, and thus is intoxicating and has an addictive potential, whereas CBD is non-intoxicating.
“WHAT IS HEMP?”
The hemp plant is a cannabis distinctly different from marijuana. It has a sturdier and longer stalk than marijuana and its leaves are noticeably different looking. The strong stalk of hemp plants are used industrially to make rope, clothing, textile and other products. The leaves are a source for the CBD-rich products that are sold to consumers. These leaves are generally more abundant in CBD with very little THC.
Note that several cannabis plants have a wide range of different cannabinoids and their impact has not been elucidated in scientific studies.
Marijuana versus Hemp
One of the main distinctions between marijuana and hemp is the difference in their levels of THC and CBD. Marijuana varieties are typically high in THC, which is why they may cause a “high” when consumed, and have varying levels of CBD. In contract, hemp has very little THC, but is rich in CBD. This is why the federal government has labeled marijuana as an illegal drug, but has made it legal to distribute hemp.
Because CBD is found in both marijuana and hemp, CBD products can be derived from either variety. However, there are many differences in the CBD derived from the two plants. The most important difference is that CBD derived from hemp has very little, or no, THC.
“SO, THEN IT’S LEGAL?”
Frankly, the answer to this is complicated. Products with less than 0.3% THC can be legally distributed, yet individual states have varying laws and restrictions. There are FDA-approved pharmaceutical-grade CBD products that have been given controlled substance scheduling. In some states, special permits are required to prescribe these prescriptions.
The drug EpidiolexRis now schedule V, the lowest restrictive schedule, but doctors can only prescribe it for a narrow range of pediatric seizure conditions: Lennox-Gastaut syndrome and Dravet syndrome. It should be noted, however, that it is difficult to decipher how much THC exists in EpidiolexR, even though it is reportedly very rich in CBD. Other FDA-approved products, such as MarinolRand its generic version Dronadinol, are labeled for the treatment of chemotherapy-induced nausea and vomiting, and HIV-related anorexia with weight loss. This pharmaceutical-grade product is a synthetic THC, and is schedule III. Another product, Nabilone, is a synthetic THC for the treatment of chemotherapy induced nausea with vomiting.
Having said all of the above, CBD can be legally purchased by the consumer online or in some local dispensaries, as long as it has less than 0.3% THC in the product.
“SO, IS CBD ADDICTIVE?”
To date, there are no studies to suggest that CBD is addictive. This cannabinoid substance does not cause euphoria. It should be noted that many products labeled “CBD” actually have several different types of cannabinoids within it, including some THC. The purer the CBD product, the less THC it can have, thus it is less likely capable of inducing euphoria. The CBD product of high purity is thus not an intoxicant. Furthermore, there is some research suggesting that CBD has a potential to treat addiction. Prudent use of CBD is likely innocuous, whereas excessive use may defeat the therapeutic goal being sought.
“WHAT AILMENTS ARE REASONABLE CANDIDATES FOR THE USE OF CBD?”
So far, there are very few ailments that have been rigorously studied to the extent that a FDA label for indication can be applied. Epilepsy has made the FDA-approval list for a pharmaceutical-grade product. However, there are encouraging studies that suggest therapeutic benefit in other ailments, such as MS-related spasticity, chronic cancer pain and neuropathic pain. Several clinical studies are also underway to decipher the benefit of CBD for the treatment of anxiety, mitigation of addiction and anti-inflammatory benefits. It will take a while to amass level A evidence in these areas, which is required by the FDA.
Anecdotally, the use of CBD products for illness are broad—from anxiety to inflammatory pain (from conditions such as arthritis), mitigation of addictive craving, and mitigation of THC-induced psychosis, to name a few.
“WHAT SIDE EFFECTS MAY I ENCOUNTER WITH CANNABIS?”
It depends on the product. THC-rich products, as commonly seen with marijuana, can cause cognitive impairment in children, adolescents and possibly even those up to 25-years-old. In these cases, there are permanent changes in the brain associated with steady use. Other side effects include the precipitation of psychosis in vulnerable individuals, marijuana-induced hyperemesis (uncontrollable nausea/vomiting), hypertensive reaction (high blood pressure that can lead to stroke), rapid heart rate, cerebral vascular spasms resulting in stroke or stroke-like events, bronchitis from smoking marijuana, and the risk of being inattentive while driving and addiction.
CBD-rich products are NOT documented to have the above list of side effects. However, a “higher than therapeutic” dose may cause orthostatic hypotension, nausea, diarrhea and fatigue. Vis-à-vis marijuana, documented side effects are generally fewer and tolerability appears to be greater. There is also no documented evidence of addiction caused by CBD.
“CAN CBD INTERACT WITH OTHER MEDICATIONS I AM TAKING?”
It is a myth to think that herbal-derived products are free of side effects or potential interactions with medications. After all, your liver and other organs process it like a drug. CBD is metabolized by liver enzymes.
To date, though, there is a void of reports suggesting serious interactions with medications. That is not to say there is no interaction potential.
“CAN YOU PRESCRIBE IT FOR ME AND TELL ME HOW TO DOSE IT?”
Now that is an area of much complexity. There is much variability between products. Whether you use an oil or a brownie, I cannot tell you how many milligrams are in your product. Furthermore, dosing for a given condition is not well established or meets the FDA level of rigorous studies for labeling.
More likely than not, you have a low risk of harm, yet a high potential for benefit. Beyond that, an active physician prescribing is not yet legal, or legal with enough clarity in my state of Texas. The onus to decipher if the CBD product is really less than or equal to 0.3% TCH makes physicians defer to patients’ discretion to pursue purchase, as one would do with any legal over-the-counter medication. We abide by medical jurisprudence.
“CAN I END UP TAKING TOO MUCH?”
Yes. Just because CBD has a relatively benign profile does not mean one could not overdo it and get dizzy, have diarrhea or nausea – like anything else, such as food, alcohol, use of a heating pad or even bed rest. It is possible to overdo it and develop nontherapeutic consequences.
“IF I AM ON OPIOID OR OTHER PRESCRIPTIONS LABELED AS CONTROLLED SUBSTANCES, CAN THE USE OF CBD LEAD TO A POSITIVE DRUG SCREEN? AND, THEREFORE, COULD THIS AFFECT MY TREATMENT CONTRACT WITH MY PHYSICIAN?”
Yes, it is possible to trigger a positive drug screen. In my experience many patients who say they are on CBD are not detected on the drug screen. It depends on the test and also the amount of THC, if that is the compound sought. A simple screen, which is typically called an ELISA method, has a relatively high false positive potential. In contrast, the LCMS/MS test is the more elaborate method to confirm with greater accuracy.
An honest and full disclosure is the best route to abreast your physician. Surely, if your using CBD results in the ability to wean off opioids or other habituating drugs, then it is highly commendable! However, a recurrently positive drug screen for THC does present a dilemma. Working with your physician to stay within the confines of existing medical jurisprudence is really important (in other words, your physician can advise you how to stay within the goal of being in a therapeutic and legally adherent confine).
“HAVE YOU SEEN PATIENTS WHO HAVE BENEFITTED BY USING CBD?”
Yes. Through their own pursuits, and the desire to actually simplify their medicinal regimen while attempting to achieve relief, I have noted that several have succeeded!
Dr. Everton Edmondson, MD
Dr. Everton Edmondson has led a successful neurology and pain medicine practice in Houston, Texas, for more than 30 years. His experience in internal medicine, neurology, pain management and pharmacology affords him the broad scope needed to provide expert consultation and second opinion in pain and neurologic conditions. He is currently an Associate Professor of Neurology at Baylor College of Medicine and Chief of Adult Neurology at Pavilion for Women, Texas Children’s Hospital.