By now you’ve certainly heard about cannabidiol, better known as CBD, a product derived from cannabis or hemp.
CBD vendors at trade shows are consistently mobbed by curious doctors, and new companies are opening almost every week. Accordingly, you might be wondering if it’s safe, if it’s effective, and if it’s legal.
The answers to these questions are clarifying as researchers and governments grapple with the burgeoning science and evidence behind CBD, and it’s safe to say that we’ll know more tomorrow than we do today. That said, it’s time to take a close look at where we stand with this promising supplement.
A rocky road
Briefly, we know from archeological discoveries that people have been using the cannabis plant for medical and possibly religious purposes since at least 500 BC (if not earlier), and our word “assassin” comes from an Arabic word (hasisi) meaning “hashish-eater,” entering English around AD 500. America’s Founding Fathers, including George Washington and Thomas Jefferson, grew hemp on their plantations, and by around the mid-1800s various medicinal preparations of cannabis were appearing in pharmacies as remedies for nausea and vomiting
In the early 1900s, Mexican immigrants introduced the practice of smoking marijuana, and it became somewhat popular until it was banned at the state level beginning in 1911. By 1933, more than half the states had outlawed cannabis, and it wasn’t until 1973 that the long process of decriminalization began—which is still ongoing.
With the passage of Proposition 215 in 1996, cannabis for medical use was legalized in California and over the next 20 years more than half the states followed suit. The federal government, however, in passing the Controlled Substances Act in 1970, officially prohibited cannabis for any use—including medicinal—by listing it as a Schedule I drug (one having no recognized medical use and a high potential for abuse).
This gets us to where things stand today. The Farm Bill passage changes the status of CBD in the eyes of the federal law. CBD is no longer in a legal gray area, opening up the possibilities immensely for new research to be done. However, medical applications of cannabis and CBD are currently still lacking the robust academic studies needed to uncover with certainty how they work because of its past legal limbo. It was previously difficult for researchers to obtain and test theories in large cohort trials.¹ Good- to high-quality studies do exist, however, with evidence that cannabis and cannabinoids have modest to moderate therapeutic value for “treating chronic pain, chemotherapy-induced nausea and vomiting, and patient-reported symptoms of spasticity associated with multiple sclerosis.”¹
Wait, back up
The previous sections mention cannabis, cannabidiol, marijuana and hemp. These terms are not freely interchangeable. Some explanation is in order
Cannabis is the name of the plant from which marijuana and hemp derive. It comes in two varieties, Cannabis sativa and Cannabis indica. Although it is commonly believed that the sativa variety is more euphoric and the indica form more relaxing, there is little to no evidence that this is true. Rather, it’s the cannabinoids, terpenes and flavones in a strain that give it its medicinal properties.2 The cross-breeding of plants has led to a general homogenization among them.
The type of cannabis called marijuana is cultivated to maximize the amount of tetrahydrocannabinol (THC) it contains, which is what gives it psychoactive properties.
On the other hand, the cannabis plant known as hemp contains almost no THC whatsoever, but it can be rich in CBD. Until now, hemp has mainly been an industry product used for its fiber.3 Confusion among lawmakers led to hemp being classified as a Schedule I drug along with marijuana. Commercially available CBD contains 0.3 percent THC or less, meaning it has no psychoactive properties.
The endocannabinoid system (ECS) is common to all mammals, and it consists of neurotransmitters and receptors found throughout the central and peripheral nervous systems. It acquired its name because it is affected by cannabis, but the body contains its own endocannabinoids, which are released by voluntary exercise—it’s what runners experience (the “runner’s high”).
THC affects the endocannabinoid system by binding to CB1 and CB2 receptors, leading to euphoric effects, in addition to impacting appetite and reducing nausea.4 CBD, on the other hand, is an agonist at TRP channels and antagonizes GPR55. In effect, it suppresses the uptake of the body’s own endocannabinoids, somewhat analogous to the action of selective serotonin reuptake inhibitors (SSRIs). CBD stops the body’s absorption of anandamide, which regulates pain. And CBD is widely known for its anti-seizure properties, pain and inflammation moderation, and it’s potentially therapeutic with respect to anorexia, metabolic syndrome-related disorders, and Parkinson’s disease, among other conditions.5
Terpenoids are common to many herbs, such as menthol, camphor, the ginkgolide and bilobalide in Ginko biloba, and are common in citrus fruits. The curcuminoids in turmeric are well-known to herbalists. Those found in cannabis include caryophyllene, which has anti-fungal and anti-inflammatory properties, and gives marijuana its characteristic aroma. It’s what drug-sniffing dogs detect. Phytol is a diterpene that increases GABA expression, which has a mild sedative effect.5 Terpenoids have powerful effects on pain cessation as well.6
The “entourage effect” was originally coined to refer to the activity of the body’s native endocannabinoids, but more recently it has been applied to the concept that cannabis plants contain a mixture of cannabinoids, terpenoids and phytochemicals. It is theorized that CBD isolates may not work as effectively as full-spectrum products as the “entourage” of components could have synergistic properties. More research is needed to confirm or disprove this hypothesis.6
Therapeutic applications
A review of the literature finds a range of claims for medical marijuana and CBD. Before recommending CBD to patients or advising them regarding their own use, weigh the evidence carefully regarding what is known and what is merely believed. These are early days and evidence-based research is ongoing.
Antipsychotic: Drugs for patients who experience symptoms along the schizophrenic spectrum are generally treated with drugs that target the dopamine D2 receptors. A study of the effect of CBD on psychosis found that it can be as effective as the antipsychotic aripiprazole, and that it indeed functions as a dopamine D2 agonist.6
Anti-seizure: CBD is well-known for its usefulness in controlling seizure disorders. In fact, one of the first companies to market CBD oil to consumers was founded to treat a child who wasn’t being helped by traditional pharmacotherapy. Its effectiveness in this regard was instrumental in changing laws in many states to legalize CBD or make it available to medical patients. Earlier this year, the FDA approved a purified CBD product called Epidiolex for treatment of severe epilepsy.7 It’s notable that the drug was approved on a fast-track basis.
Anti-anxiety: Most users of CBD report it having a calming effect and attest to feelings of general wellness and relaxation. This may make it an appropriate treatment for patients with neuropsychiatric disorders, such as panic disorder (PD), generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), social anxiety disorder (SAD), and obsessive-compulsive disorder (OCD).8 Standard treatments for these types of patients is with SSRIs and benzodiazepines, which convey considerable risks of side effects and dependency.
Antioxidant: As mentioned above, CBD has anti-fungal properties and is protective in a number of ways, including anti-inflammatory effects from the action of several of its components. It has been shown to suppress the transcription of many proinflammatory genes.9 One study found that THC extracts had limited effect in controlling cancer cells, but CBD was highly effective at preventing cell growth and causing apoptosis (cell death) in cervical cancer lines, and may prove useful in inhibiting prostate and breast cancer growth.10 More research is needed in this area.
Analgesic: One way that CBD appears to mitigate pain is by potentiating glycine receptors, glycine being an inhibitory neurotransmitter in the brain and spinal cord.11 Virtually every drug developed for treating chronic, inflammatory and neuropathic pain comes with adverse side effects. Lab studies have found that CBD is not only effective in this regard, but it appears to have no tolerance-building aspect. Unlike with many drugs aimed at long-term pain management, CBD remains effective at a standard dose over time.
But is it legal?
This has always been the overarching issue regarding cannabidiol because it has existed in a legal gray area for most of its existence. The constant flux of legality is often the reason DCs are wary of recommending it to their patients, despite its numerous benefits. However with the passing of the Agriculture and Nutritional Act or Farm Bill, industrial hemp is now legalized. This cannabis strain is critical to the CBD industry. This removes hemp and any hemp derivative from the Controlled Substances Act, legally separating it from marijuana and putting its supervision under the Department of Agriculture.
“The passing of the 2018 Farm Bill is a huge victory for natural medicine in the United States and the supplement industry. We will now be able to safely and effectively provide hemp/CBD products to people in all 50 states without any doubt of legality,” said S. Michael Lioon, co-founder of TruGen3. “Patients suffering from illnesses such as inflammation, anxiety, seizures, sleep, and neurological conditions will now be able to legally obtain an all natural product to support their conditions. And for companies with hemp/CBD products, we will now be able to market our products across all media platforms without any restrictions. This is really a win for all parties involved.”
The Farm Bill is a huge win for the CBD industry, but does not create a completely free system where anyone can grow hemp whenever or wherever they want. In order to be classified as industrial hemp, it cannot contain more than 0.3 percent THC. States will also have submit plans to license and regulate hemp to the USDA before operations can commence. But as a DC, you can rest easy knowing that recommending CBD is no longer in legal limbo.
Dosage and protocols for use are largely patient-dependent. Experts advise “starting low and slow.”12 In one study, participants were given varying doses of CBD prior to giving a public talk—traditionally a highly stressful experience for most people. It was found that increasing the amount of CBD reduced the speakers’ anxiety up to a point, beyond which it had the opposite effect.13 Therefore, patients should self-titrate to the amount medically efficacious, and sustain their dosage to that degree.
The landscape regarding what is known about CBD and what its therapeutic applications are in a continuous state of flux. At the moment, it appears to be an effective treatment for a variety of conditions, and it has no apparent drug-supplement interactions, tolerance-building effects, or overdose potential. It is extremely safe and well tolerated. Whether you recommend it to patients or not, CBD should be on your radar as a promising supplement for numerous acute and chronic health conditions.
Daniel Sosnoski is the former editor-in-chief of Chiropractic Economics.
References
1 National Academies of Sciences, Engineering, and Medicine. “Therapeutic Effects of Cannabis and Cannabinoids.” In: The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017: 85-127.
2 Pellati F, Brighenti V, Sperlea J. New Methods for the Comprehensive Analysis of Bioactive Compounds in Cannabis sativa L. (hemp). Molecules. 2018;23(10):pii E2639.
3 Pollio A. The Name of Cannabis: A Short Guide for Nonbotanists. Cannabis Cannabinoid Res. 2016;1(1):234-238.
4 Kaur R1, Ambwani SR, Singh S. Endocannabinoid System: A Multi-Facet Therapeutic Target. Curr Clin Pharmacol. 2016;11(2):110-7.
5 Rosenberg EC, Tsien RW, Whalley BJ, Devinsky O. Cannabinoids and Epilepsy. Neurotherapeutics. 2015;12(4): 747-768.
6 Russo EB. Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. Br J Pharmacol. 2011;163(7): 1344-1364.
7 Seeman P. Cannabidiol is a partial agonist at dopamine D2High receptors, predicting its antipsychotic clinical dose. Transl Psychiatry. 2016;6(10): e920.
8 U.S. Food & Drug Administration. “FDA approves first drug comprised of an active ingredient derived from marijuana to treat rare, severe forms of epilepsy.” U.S. Dept. of Health and Human Services. https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm611046.htm. Published June 2018. Accessed Nov. 2018
9 Blessing EM, Steenkamp MM, Manzanares J, Marmar CR. Cannabidiol as a Potential Treatment for Anxiety Disorders. Neurotherapeutics. 2015;12(4):825-36.
10 Kozela E, Juknat A, Gao F, et al. Pathways and gene networks mediating the regulatory effects of cannabidiol, a nonpsychoactive cannabinoid, in autoimmune T cells. J Neuroinflammation. 2016;13(1):136.
11 Sindiswa T. et al. Cannabidiol rather than Cannabis sativa extracts inhibit cell growth and induce apoptosis in cervical cancer cells. BMC Complement Altern Med. 2016;16(1):335.
12 Xiong W, Cui T, Cheng K, et al. Cannabinoids suppress inflammatory and neuropathic pain by targeting α3 glycine receptors. J Exp Med. 2012;209(6):1121-1134.
13 Stankiewicz A. “Cannabidiol is a remarkably versatile option for wellness.” Chiropractic Economics. https://www.chiroeco.com/cannabidiol-2. Published Sept. 2018. Accessed Nov. 2018.
14 Bergamaschi MM, Queiroz RH, Chagas MH, et al. Cannabidiol reduces the anxiety induced by simulated public speaking in treatment-naïve social phobia patients. Neuropsychopharmacology. 2011;36(6):1219-26.
