Bari Platter, MS, RN, received an important reminder of the unknowns around cannabidiol (CBD) when someone recommended to her mother that she take edible CBD for pain she was experiencing before surgery.
Platter, a clinical nurse specialist at the Center for Dependency, Addiction & Rehabilitation (CeDAR) at the University of Colorado Hospital, says that rather than visiting a retailer where she could have purchased legal hemp-based CBD, her mother bought from a Boulder marijuana dispensary a package of caramels that advertised “very little or no THC.”
“I had her get her reading glasses on and look at the printout,” Platter tells Addiction Professional. The product turned out to be one-third THC (tetrahydrocannabinol), the psychoactive compound in cannabis.
“Two of those caramels would have given Mom a legal dose of THC,” Platter says.
A CBD craze that has given rise to a barrage of products from tinctures to milkshakes has fueled a spectrum of opinions, running the gamut from long-awaited cure-all to latest-vintage snake oil. The topic has started to hit home for substance use treatment professionals because patients are increasingly asking clinicians about CBD and whether it could help them with pain, anxiety and a host of other ills.
Compounding the challenge for clinicians in delivering accurate information is confusion over the actual content of largely unregulated CBD-containing products—and at a time when patient perception of risk from use of marijuana has declined steeply.
At a June National Conference on Addiction Disorders (NCAD) panel series event in Charlotte, N.C., on marijuana trends, an audience member revealed that she had been scolded by fellow clinicians in her program for trying to answer patient questions about CBD. Her colleagues' reasoning was that even talking about CBD would somehow encourage patients to use marijuana or other dangerous drugs.
Platter doesn't buy into that thinking, likening it to the debunked notion that teaching sex education in schools would encourage more young people to become sexually active. This may be a powerful analogy for addiction treatment programs to consider. Because when celebrities from Whoopi Goldberg to Kim Kardashian to Rob Gronkowski are out there promoting or directly marketing CBD products, the implication is clear: If patients don't receive advice about CBD through a reputable health care provider, they're going to learn about it on the streets.
Sidestepping the issue
Still, it is clear from the results of inquiries to sources interviewed for this article that addiction treatment programs are having as tough a time organizing their talking points about CBD as the Food and Drug Administration (FDA) is having in policing unsubstantiated health claims about CBD products.
A spokesperson for a prominent adolescent treatment program whose leaders declined to comment for this article called CBD a “loaded topic.” The representative suggested that while CBD might generate benefits for adults, it is not something the facility's clinicians would recommend for their adolescent patients.
Prevention specialist Jessica Montana, Latino program manager at the Center for Prevention Services in Mecklenburg County, N.C., says some young people in her community who are using CBD to relieve stress believe it is completely safe. But others in the community aren't as sure, and Montana tells Addiction Professional that her prevention agency cautions that a product with no established purity standards carries some degree of risk.
“Was it extracted from marijuana or from hemp?” Montana says. “If it was extracted from marijuana, maybe they didn't do a good job extracting.”
She adds it is important for individuals to know that CBD, like any product touted as “natural,” still confers interaction risks similar to those present for pharmaceuticals.
Platter points out that while a study published in 2017 in the New England Journal of Medicine found a moderate effect for CBD in reducing seizures, it also showed an active side effect profile, with treatment-emergent gastrointestinal symptoms and fatigue occurring in a substantial number of subjects. “People think of 'natural' as completely safe,” she says.
What we do know
Here are some important baseline facts about CBD:
Both legal hemp and (largely) illegal marijuana produce CBD and other cannabinoids. The 2018 Farm Bill opened the door for legal possession of hemp-based CBD products as long as they contain no more than 0.3% THC. The kinds of marijuana-generated CBD that Platter's mother bought at the Colorado dispensary have become a ubiquitous presence in some communities, especially in states that have legalized recreational use of marijuana. Platter says many dispensaries are now carrying “CBD” products that are largely generated from the marijuana components that are discarded in production of their THC product lines.
The contents of many CBD products have not been verified by an independent third party, so fears of mislabeling appear well-founded. One study published in JAMA reported that around half of the products that its researchers examined contained ingredients not fully reflected in labeling.
There is currently one FDA-approved product containing CBD on the market, but it won't likely lead to widespread use in medicine. The brand-name drug Epidiolex, approved by the FDA in 2018, is an oral solution used to treat two rare and severe forms of epilepsy.
The FDA has said it is seeking to monitor the burgeoning CBD marketplace for deceptive advertising, but The New York Times reported this month that the federal agency has filed only nine warning letters against CBD companies since 2017. At the time Epidiolex was approved last year, then-FDA Commissioner Scott Gottlieb said in the agency's announcement, “We'll continue to support rigorous scientific research on the potential medical uses of marijuana-derived products and work with product developers who are interested in bringing patients safe and effective, high-quality products. But, at the same time, we are prepared to take action when we see the illegal marketing of CBD-containing products with serious, unproven medical claims.”
These “buyer beware” concerns were echoed by Ben Cort, a prominent voice in the addiction field on topics ranging from marijuana policy to treatment center marketing, in an August 2019 Golf Digest article on CBD's sudden appeal in both professional and recreational golf. While acknowledging the potential of hemp-derived CBD, Cort said, “When you have a product that's celebrity-endorsed yet non-FDA-approved, we really run the risk of creating a massive excitement and culture around this thing where we don't know what people are using, nor do we know a lot of the long-term effects.”
Pain center's perspective
Osvaldo Cabral has worked in both the addiction treatment and pain management fields. Formerly a close colleague of Platter on CeDAR's clinical staff, Cabral now serves as director of integrated services at New Health Services, an Englewood, Colo., chronic pain clinic that opened in May 2018. Cabral says that some patients in the clinic, which offers integrated pain management and behavioral health services, already were using CBD oil at the time they initiated treatment there.
When that is the case, Cabral says, staff will discuss the potential pros and cons of CBD with the patient. However, “We have not yet initiated conversations [about CBD],” Cabral tells Addiction Professional. “We just talk about it if they're already on it.”
Animal research has shown promising findings for CBD's effects in areas such as inflammation and seizures, but Cabral says it largely remains to be seen how that will translate to humans. Another challenge for future research involves precisely defining what effects are attributable to CBD, and whether and how they are distinct from THC's effects.
Of course, none of this uncertainty is slowing the progress of a CBD industry that one cannabis-focused group has estimated could reach a value of $22 billion within the next three years.
Cabral describes the prevailing sentiment he hears as, “Wow, CBD oil cures everything,” from anxiety to seizures to sleep problems and beyond.
Talking to patients
Especially in a legalization state such as Platter's Colorado, she believes it is critical for treatment professionals to advise CBD-curious patients on their buying outlet options.
“When we're lackadaisical about patients going into a dispensary, they may go to one where the person who works there is likely to be high at work,” Platter says.
Professionals should urge patients to opt for hemp-based CBD only, and to obtain the product from a reputable retailer such as a Whole Foods as opposed to a marijuana dispensary, Platter says.
Also, patients should be reminded that the research evidence remains sparse so far, so they should remain on guard about how CBD products could affect them.
Both patient and provider education remain critically important, Platter believes. “It's important for us as providers to be up to date, to know what's happening on the street,” she says. “I go to a dispensary from time to time, to know what's going on there.”