When should I recommend CBD? While CBD oil may offer some therapeutic benefits, inconsistent labelling, an unknown therapeutic window, and a lack of quality human clinical investigations supporting its use should caution clinicians from recommending CBD oil to their patients (2). Much like other untested supplements, clinicians should inquire about its use in a non-judgmental, open-minded fashion.
Background CBD has received public interest as an antidote for pain, epilepsy, anxiety, and nausea (1-4). In the United States (US), there is one FDA approved CBD-based medication – epidiolex – which is indicated for refractory seizures from disorders such as Lennox-Gastaut syndrome and Davet syndrome at a usual dose range of 2.5 to 20 mg/kg twice a day. More commonly though, CBD refers to non-regulated oil which is either derived from a marijuana plant (true CBD oil) or a hemp plant (hemp oil) (5). This Fast Fact addresses common clinical questions about CBD oil. For more general information on the use of cannabinoids in palliative care, see Fast Fact #279.
What is the difference between THC and CBD? The cannabis plant produces more than one hundred cannabinoids (1). At least two of these, delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), have potential use for symptom management (1,6). While THC is associated with CNS-altering effects, CBD oil is non-intoxicating at least in doses up to 600 mg and it does not appear to convert to THC in vivo (1,5). Most cannabinoid research has focused on THC which activates cannabinoid receptors CB1 and CB2 or THC/CBD combination products. However, CBD-only products have garnered attention as a potentially safer therapy, with some researchers even suggesting that CBD could minimize the intoxication effects of THC when used in combined formulations via CB1 receptor antagonism (5).
Author Affiliations: Mayo Clinic, Rochester, MN; University of Pittsburgh Medical Center, Pittsburgh PA.Version History: Originally edited by Sean Marks MD; first electronically published in December 2018.
Are the products labeled accurately? The FDA has issued numerous warnings to vendors about mislabeling (7). A recent study examining the accuracy of online CBD products found that only 30% of products accurately labeled the CBD dose: most understated the CBD dose, a quarter overstated the dose, and some formulations contained no measurable amount of CBD (23). Approximately one fifth contained THC which raises intoxication concerns, particularly when given to children (23).
What research do we have on CBD for pain? No randomized controlled trials of CBD-only products for pain management in humans exist (6,8). Most of the supporting data comes from mouse models, including studies on paclitaxel-induced pain and arthritis (9-11). One case series of seven kidney-transplant patients who requested CBD for chronic pain showed it to be effective in relieving pain in 6 of the patients and no adverse effects were reported (12). There are yet no convincing data that CBD is an opioid-sparing analgesic in humans. Published results of a combined THC/CBD oromucosal spray have been mixed. Three long-term perspective studies showed improved pain control, but neuro-psychiatric effects contributed to a discontinuation rate of 23% (13-16). A systematic review on THC/CBD did not show clinically significant benefits for neuropathic pain (13).
What are the side effects of CBD oil? In general, they are mild and include nausea, dry mouth, dizziness, and drowsiness (12). A few studies raised concern for more serious side effects (9, 18-20). In a pediatric study of CBD oil for epilepsy, nearly 20% had elevated LFTs (18). Other studies have associated the use CBD oil with compromised effects on reproductive hormones (9,19). The risk of drug interactions is not firmly established, although many experts suggest this risk would be low (20).
The study also found that, even in states where it is illegal, patients are using MC – an indication that, from the patient’s point of view, the perceived benefits outweigh the legal risks.
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AR: To what degree is MC still kept in the closet for hospice use?
In spite of their overall support for MC, the survey responders cited concerns regarding the disparities between state and federal law, as well as a general confusion and discomfort over their inadequate knowledge and training on MC, its use, clinical efficacy and safety, particularly as it relates to the actual products their patients are using.
On the other hand, responders expressed concerns that as healthcare providers, they were prevented from being able to provide a medicine they believe could help their patients, and that some of those patients would not be able to access it because of the costly out-of-pocket expense.