Cannabidiol (CBD) has gained significant popularity in recent years for its therapeutic properties. Derived from the cannabis plant, CBD is distinguished as a non-addictive substance, unlike its counterpart tetrahydrocannabinol (THC), which is also found in cannabis and is known for its therapeutic benefits but is addictive.
CBD exerts its effects by mimicking the actions of endogenous cannabinoids within the body's endocannabinoid system. This system comprises CB1 receptors primarily located in the brain and central nervous system, and CB2 receptors found in peripheral organs, particularly those involved with the immune system. By interacting with these receptors, CBD can offer therapeutic relief for conditions such as anxiety, chronic pain, insomnia, and various other ailments. It has also demonstrated potential in alleviating nerve pain and exhibiting anti-cancer properties.
The efficacy of CBD products lies in their ability to influence the endocannabinoid system, which regulates numerous physiological processes including mood, energy levels, immune function, pain perception, and stress response. Disruptions in this system can impact the progression of various diseases, making CBD a versatile treatment option.
CBD products come in various forms including oils, lotions, capsules, and more, offering alternatives to traditional medications with potentially fewer side effects. However, despite its natural origins, there are misconceptions surrounding CBD. It is often wrongly perceived as the beneficial component of cannabis while THC is seen negatively due to its psychoactive effects and potential for abuse. Both compounds, when used appropriately and in controlled doses, can offer therapeutic benefits. It's crucial to note that while many CBD products are available over-the-counter, they are not regulated by the FDA for safety and efficacy. The FDA warns against mislabeling and unsubstantiated medical claims associated with CBD products, emphasizing the importance of using them as directed.
Epidiolex stands as the sole FDA-approved CBD product, specifically prescribed since 2018 for treating seizures associated with Lennox-Gastaut syndrome, Dravet syndrome, and tuberous sclerosis complex in pediatric patients aged one year and older. Initially classified as a Schedule I drug (reserved for substances with high abuse potential and no recognized medical use), Epidiolex was later reclassified to Schedule V following extensive research demonstrating its therapeutic benefits and minimal risk of abuse. It is administered orally as a solution with a concentration of 100 mg/mL, with dosing adjusted based on the specific condition and patient's response, while hepatic function monitoring is essential due to potential liver-related side effects.
While CBD offers natural advantages, its consumption should be approached with caution regarding potential adverse effects. Natural does not equate to completely safe, and proper dosage adherence is essential to mitigate risks associated with its use. Understanding these nuances ensures that individuals can safely harness the therapeutic benefits of CBD while minimizing potential drawbacks.
Rapin, L., Gamaoun, R., El Hage, C., Arboleda, M. F., & Prosk, E. (2021). Cannabidiol use and effectiveness: real-world evidence from a Canadian medical cannabis clinic. Journal of cannabis research, 3(1), 19. https://doi.org/10.1186/s42238-021-00078-w
Iffland, K., & Grotenhermen, F. (2017). An Update on Safety and Side Effects of Cannabidiol: A Review of Clinical Data and Relevant Animal Studies. Cannabis and cannabinoid research, 2(1), 139–154. https://doi.org/10.1089/can.2016.0034
Cannabidiol has surged in popularity in recent years, emerging as a key player in the health and wellness industry. As an active compound derived from the cannabis plant, CBD offers a range of potential health benefits, leading to its widespread adoption in pharmacy settings. CBD is primarily known for its potential therapeutic effects, which have led to its use in various pharmacy products. One of the most common uses of CBD is in the treatment of chronic pain, with studies suggesting that it may help alleviate pain associated with conditions such as arthritis and multiple sclerosis. Another key use of CBD in pharmacy is in the management of anxiety and depression. Research has shown that CBD may have anxiolytic and antidepressant effects, making it a potentially valuable addition to the treatment options available for these conditions. In addition to pain and mental health disorders, CBD is also being studied for its potential role in treating other health issues, including epilepsy, acne, and neurodegenerative disorders such as Alzheimer's disease.
One of the key benefits of CBD in pharmacy is its perceived safety profile. Unlike tetrahydrocannabinol (THC), another compound found in cannabis, CBD is not psychoactive, meaning it does not produce the "high" typically associated with cannabis use. This makes CBD a more appealing option for many patients seeking natural alternatives to traditional pharmaceuticals. CBD is generally well-tolerated, with few reported side effects. This makes it a potentially attractive option for patients who may not tolerate the side effects of traditional medications. While CBD is generally considered safe, it is not without risks. Some studies have suggested that high doses of CBD may cause liver toxicity in animals. CBD can interact with certain medications, potentially affecting their efficacy. It is important for pharmacists to be aware of these potential interactions and advise patients accordingly.
In conclusion, CBD has emerged as a popular and potentially beneficial addition to pharmacy products. While more research is needed to fully understand its effects, CBD shows promise as a natural alternative for a range of health issues. Pharmacists play a crucial role in educating patients about the uses, benefits, and risks of CBD, helping them make informed decisions about their health and wellness.
References
Pamplona, F. A., da Silva, L. R., & Coan, A. C. (2018). Potential clinical benefits of CBD-rich cannabis extracts over purified CBD in treatment-resistant epilepsy: observational data meta-analysis. Frontiers in Neurology, 9, 759.
Blessing, E. M., Steenkamp, M. M., Manzanares, J., & Marmar, C. R. (2015). Cannabidiol as a potential treatment for anxiety disorders. Neurotherapeutics, 12(4), 825-836.
Palmieri, B., Laurino, C., & Vadalà, M. (2019). A therapeutic effect of cbd-enriched ointment in inflammatory skin diseases and cutaneous scars. Clinical Therapeutics, 170(4), e230-e237.
Iffland, K., & Grotenhermen, F. (2017). An update on safety and side effects of cannabidiol: a review of clinical data and relevant animal studies. Cannabis and Cannabinoid Research, 2(1), 139-154.
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익명 회원
2022년 4월 26일
CBD for PainWritten by Justin Ayob and Antonio OrtegaCannabidiol (CBD) is a nonintoxicating Phyto cannabinoid extracted from Cannabis sativa, primarily found in the flowers and leaves of the cannabis plant. Of the many cannabinoids present in Cannabis, Δ9tetrahydrocannabinol (Δ9-THC) and cannabidiol are the two components found at the highest concentrations. In recent years Cannabidiol’s availability has increased as more changes are being made to federal and state regulations across the country. With legislative action taking place, the market for CBD as a sole agent, as opposed to in combination with THC in medical marijuana) is rapidly expanding. CBD marketed products such as gummies, body lotions, oils for oral ingestion, and even cartridges for vaping are now being stocked at pharmacies in many states. The anterolateral system where pain perception and modulation are mediated, include nociceptors that signal and give rise to acute pain. Tissue damage that leads to inflammation mediates chronic pain known as inflammatory nociceptive pain. CBD regulates the endocannabinoid system which is present at essentially all levels of the anterolateral system and seems to play an unknown role in immunoinflammatory responses. As of today, there is not enough clinical data to support CBD as a sole agent in the treatment of pain. According to multiple clinical trials CBD has been shown to be well tolerated in children with seizure disorders, but its safety profile in adults with chronic health conditions remain unknown. Of at least 19 registered clinical trials evaluating CBD’s effect on pain, most have not begun recruiting trial candidates while others have not listed clinical trial results. While CBD continues to grow in popularity in the states and many have reported varying benefits to the use of CBD it is important to remember as pharmacists to inform patients that there is insufficient evidence to knowingly recommend the use of CBD for pain management. References:
· Mlost, Jakub et al. “Cannabidiol for Pain Treatment: Focus on Pharmacology and Mechanism of Action.” International journal of molecular sciences vol. 21,22 8870. 23 Nov. 2020, doi:10.3390/ijms21228870
· Svensson, Craig K. “CBD for the treatment of pain: What is the evidence?.” Journal of the American Pharmacists Association : JAPhAvol. 60,6 (2020): e80-e83. doi:10.1016/j.japh.2020.06.009
Marijuana refers to the dried leaves, flowers, stems, and seeds from the cannabis sativa or cannabis indica plant. When it comes to this plant, most people think of stoners, Woodstock, hallucinations, and getting high. There is way more to this plant, what people with the stigmas against marijuana is just THC (the cannabinoid responsible for the “high effect”) Moreover, there are many other cannabinoids found in marijuana including cannabidiol (CBD). CBD is the second most prevalent active ingredient in cannabis which does not exhibit any “high” effects.
CBD has grown in popularity recently and has been tested in various countries for its therapeutic properties. CBD is being researched and marketed as an alternative method of treatment to certain pharmaceutical agents that contain harsh side effects. This can be used as an aid in relief to chronic pain, anxiety, inflammation, depression, and other conditions. There are a wide range of diseases in which CBD is thought to be beneficial such as: autoimmune diseases (inflammation, rheumatoid arthritis), neurological conditions (Alzheimer’s, dementia, Parkinson’s, multiple sclerosis, epilepsy, Huntington’s chorea, traumatic brain injury), metabolic syndrome (diabetes, obesity), neuropsychiatric illness (autism, ADHD, PTSD, alcoholism), gut disorders (colitis, Chron’s), cardiovascular dysfunction (atherosclerosis, arrhythmia), and skin disease (acne, dermatitis, psoriasis).
In a double blind multi-centered controlled trial, patients with schizophrenia were randomized in a 1:1 ratio to receive CBD (1000 mg/day; N=43) or placebo (N=45) alongside their existing antipsychotic medication. Participants were assessed before and after treatment using the Positive and Negative Syndrome Scale (PANSS), the Brief Assessment of Cognition in Schizophrenia (BACS), the Global Assessment of Functioning scale (GAF), and the improvement and severity scales of the Clinical Global Impressions Scale (CGI-I and CGI-S). After 6 weeks of treatment, compared with the placebo group, the CBD group had lower levels of positive psychotic symptoms (PANSS: treatment difference=-1.4, 95% CI=-2.5, -0.2) and were more likely to have been rated as improved (CGI-I: treatment difference=-0.5, 95% CI=-0.8, -0.1) and as not severely unwell (CGI-S: treatment difference=-0.3, 95% CI=-0.5, 0.0) by the treating clinician. Patients who received CBD also showed greater improvements that fell short of statistical significance in cognitive performance (BACS: treatment difference=1.31, 95% CI=-0.10, 2.72) and in overall functioning (GAF: treatment difference=3.0, 95% CI=-0.4, 6.4). CBD was well tolerated, and rates of adverse events were similar between the CBD and placebo groups. These results mean that CBD has beneficial effects in patients with schizophrenia and the effects do not depend on dopamine receptor antagonism that the other treatments rely on.
Greenwich biosciences has marketed CBD under the name Epidiolex, resulting in the 1st and only FDA-Approved Rx of CBD. Currently, it is approved to treat seizures associated with lennox-gastaut syndrome (LGS), Dravet syndrome, or tuberous sclerosis complex (TSC) in patients 1 year of age and older. Epidiolex is an oral solution of 100mg/ml and it is taken twice daily with meals. Even though CBD on its own is legal and sold over the counter, there are many benefits to having a prescription version. Since it is FDA approved, it undergoes strict regulation such as being grown without GMO, heavy metals, or pesticides, resulting in higher quality, safety, and efficacy of the drug. Additionally, the guidelines for CBD such as the quantity, grade, and precautions are clearly listed on the label, resulting in consistency and stability. Non-FDA approved CBD does not have to contain what might be on the label.
In conclusion, as the world transitions to breaking the stigma against parts of the marijuana plant. It is my hope that we continue to research the health benefits and provide better treatment to our patients.
References:
EPIDIOLEX® (cannabidiol). EPIDIOLEX.com. https://www.epidiolex.com/about-epidiolex. Accessed June 7, 2021.
Epidiolex(package insert). Carlsbad, CA. Greenwich Biosciences. 2020
McGuire P, Robson P, Cubala WJ, et al. Cannabidiol (CBD) as an Adjunctive Therapy in Schizophrenia: A Multicenter Randomized Controlled Trial. Am J Psychiatry. 2018;175(3):225-231. doi:10.1176/appi.ajp.2017.17030325
National Institute on Drug Abuse. Marijuana DrugFacts. National Institute on Drug Abuse. https://www.drugabuse.gov/publications/drugfacts/marijuana. Published June 4, 2021. Accessed June 7, 2021.
Prior to the 19th century, little was known about epilepsy despite it being one of the most common neurological disorders. In 2015, 1.2% of Americans had active epilepsy. This is estimated to be roughly 3.4 million people with active epilepsy in the United States of America. Epilepsy is defined as a disorder of recurrent seizures. Roughly 125,000 people in the US are diagnosed w/ epilepsy every year. Roughly 30% are younger than 18 y/o at diagnosis. Around 5% of the world population experiences at least one lifetime seizure. 30-40% of patients continue to seize despite using anti-epileptic drugs (AED). The majority of patients complain of drowsiness or difficulty in concentration with his or her current therapy.
A patient is considered to have epilepsy when she or he has had two or more unprovoked seizures (with or without convulsions). The clinical definition of a seizure is the clinical manifestations or symptoms of disturbed electrical activity.
International League Against Epilepsy (ILAE) classified
epilepsy according to category, defined by onset
features, and etiology. The two major categories of epilepsy are- 1. Generalized- absence, tonic-clonic, myoclonic and 2. Partial- simple partial seizures (patient has no loss of consciousness), complex partial seizures (patient has loss of consciousness). Non-pharmacological options include a vagal nerve stimulator which is an implanted medical device, ketogenic diet, and/or surgery. I wasn’t aware of the ketogenic diet being a primary determinant in treating epilepsy so I am glad that I learned something completely new. More specifically, both the Modified Atkins Diet (MAD) and ketogenic diet are high fat and low carbohydrate diets that have been proven to reduce the number of seizures in both children and adults with epilepsy. Roughly half of the people who initiate and maintain these diet therapies will see over a 50% improvement in seizures. This must be done under supervision of a registered dietitian and in close coordination with the epilepsy physicians- as healthcare professionals it is crucial to be able to help people choose, initiate, and maintain the diets safely.
The very first and only FDA-approved medication containing cannabidiol is Epidiolex. As indicated on the package insert, Epidiolex is indicated for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients 2 years of age and older. The only dosage form it is available as is as an oral solution and the only strength available is as 100 milligrams per milliliter.
Lennox-Gastaut syndrome (LGS) is a rare type of epilepsy. Patients with LGS experience many different types of seizures including- 1. Tonic- stiffening of the body, 2. Atonic- temporary loss of muscle tone and consciousness, causing the patient to fall, 3. Atypical absence - staring episodes, and 4. Myoclonic- sudden muscle jerks. Dravet syndrome, also known as Severe Myoclonic Epilepsy of Infancy (SMEI), is also a rare form of epilepsy that is unfortunately very difficult to treat that begins in infancy and proceeds with morbidity that has a significant impact on individuals throughout their lifetime. Dravet syndrome has an estimated incidence rate of 1:15,700 individuals, 80% of whom have a mutation in their Sodium Voltage-Gated Channel Alpha Subunit 1 (SCN1A) gene. All in all, it is important that CBD can be implemented in medications for rare disorders and for many other disorders in general.
Cannabidiol, also known as CBD, has been on the rise for the past few years. CBD provides many therapeutic effects. It originates from the cannabis plant and it is a non-addictive substance. CBD is often associated with tetrahydrocannabinol (THC) which is another component from the cannabis plant. THC is known for its therapeutic effect as well as its addictive effect on the body.
CBD works in our bodies by copying the effects of the body’s natural compound called endogenous cannabinoids which are part of the endocannabinoid system. The endocannabinoid system has two parts in which CBD can perform its therapeutic effect. CBD can work on CB1 receptors which are mainly found in the brains and central nervous system. CBD can also work on CB2 receptors which work on the peripheral organs especially those that work with the immune system.
CBD products are great alternatives that act as natural pain relievers from not only medication side effects but also for those who suffer from anxiety, chronic pain, lack of sleep, and other conditions. CBD has also been shown to help against nerve pain as well as have anti-cancer properties. The reason CBD products can have an effect on different diseases is because the endocannabinoid system functions by regulating different processes in our body such as our mood, energy level, immune activity, pain threshold, stress, and others. If the endocannabinoid system is disrupted then it can affect different disease progressions in the body.
CBD products come in different formulations such as oils, lotions, vitamins, roll-ons, capsules, and others. CBD products are effective but there are a few misconceptions that accompany the use of CBD. Many people associated CBD as being the good part of cannabis and THC as being the bad part of cannabis. Both CBD and THC have great therapeutic effects on the body if consumed in the correct doses. THC is not only for recreational purposes but people can abuse it when it is not used correctly. Although a lot of CBD products are sold over-the-counter, they do have protentional harmful side effects. CBD products are not approved by the food, Drug, and Administration Act (FDA) but the FDA does warn against any CBD products that are mislabeled and marketed with unproven medical claims. It is important to use CBD in the correctly labeled doses and to not exceed the limit. It does not mean because it is over-the-counter then it is safe to overuse.
There is only one FDA approved CBD product on the market that is a prescription drug. Epidiolex is a CBD product approved in 2018 and is used to treat seizures in pediatric population. The seizures it treats are associated with Lennox-Gastaut syndrome, Dravet syndrome, or tuberous sclerosis complex. It can be used in patients 1 year of age and older. Interestingly, Epidiolex used to be considered a schedule I drug which is a category for dangerous drugs such as heroin. Drugs in such category are not typically used. Later, once more CBD studies were made, the Drug Enforcement Administration (DEA) removed Epidiolex from Schedule I to Schedule V category. Schedule V is the least dangerous category for controlled medications under the Controlled Substances Act. Epidiolex comes as an oral solution with 100 mg/ mL The usual dosing for patients who have seizures associated with Lennox-Gastaut Syndrome or Dravet Syndrome is 2.5 mg/kg by mouth twice daily and it can be increased to a maintenance dose of 5 mg/kg twice daily after one week. The maximum dose a patient can be on for this medication is 10 mg/kg twice daily. The usual dosing for patients who have seizures associated with Tuberous Sclerosis Complex is also 2.5 mg/kg by mouth twice daily and it can be increased weekly by 2.5 mg/kg twice daily which a maximum recommended maintenance dose of 12.5 mg/kg twice daily. It is important to monitor hepatic function when taking this medication, therefore patients with liver damage need a dose adjustment when taking this medication.
CBD has great natural benefits on the body. Many people prefer it due to its natural properties but it is important to be mindful of its side effects. It does not mean because something is natural that it is safe to consume in large quantities.
“What Is CBD?” Definition of Cannabidiol & CBD Oil, www.projectcbd.org/about/what-cbd.
Commissioner, Office of the. “What to Know About Products Containing Cannabis and CBD.” U.S. Food and Drug Administration, FDA, www.fda.gov/consumers/consumer-updates/what-you-need-know-and-what-were-working-find-out-about-products-containing-cannabis-or-cannabis.
Marijuana refers to the dried leaves, flowers, stems, and seeds from the cannabis sativa or cannabis indica plant. When it comes to this plant, most people think of stoners, Woodstock, hallucinations, and getting high. There is way more to this plant, what people with the stigmas against marijuana is just THC (the cannabinoid responsible for the “high effect”) Moreover, there are many other cannabinoids found in marijuana including cannabidiol (CBD). CBD is the second most prevalent active ingredient in cannabis which does not exhibit any “high” effects.
CBD has grown in popularity recently and has been tested in various countries for its therapeutic properties. CBD is being researched and marketed as an alternative method of treatment to certain pharmaceutical agents that contain harsh side effects. This can be used as an aid in relief to chronic pain, anxiety, inflammation, depression, and other conditions. There are a wide range of diseases in which CBD is thought to be beneficial such as: autoimmune diseases (inflammation, rheumatoid arthritis), neurological conditions (Alzheimer’s, dementia, Parkinson’s, multiple sclerosis, epilepsy, Huntington’s chorea, traumatic brain injury), metabolic syndrome (diabetes, obesity), neuropsychiatric illness (autism, ADHD, PTSD, alcoholism), gut disorders (colitis, Chron’s), cardiovascular dysfunction (atherosclerosis, arrhythmia), and skin disease (acne, dermatitis, psoriasis).
In a double blind multicentered controlled trial, patients with schizophrenia were randomized in a 1:1 ratio to receive CBD (1000 mg/day; N=43) or placebo (N=45) alongside their existing antipsychotic medication. Participants were assessed before and after treatment using the Positive and Negative Syndrome Scale (PANSS), the Brief Assessment of Cognition in Schizophrenia (BACS), the Global Assessment of Functioning scale (GAF), and the improvement and severity scales of the Clinical Global Impressions Scale (CGI-I and CGI-S). After 6 weeks of treatment, compared with the placebo group, the CBD group had lower levels of positive psychotic symptoms (PANSS: treatment difference=-1.4, 95% CI=-2.5, -0.2) and were more likely to have been rated as improved (CGI-I: treatment difference=-0.5, 95% CI=-0.8, -0.1) and as not severely unwell (CGI-S: treatment difference=-0.3, 95% CI=-0.5, 0.0) by the treating clinician. Patients who received CBD also showed greater improvements that fell short of statistical significance in cognitive performance (BACS: treatment difference=1.31, 95% CI=-0.10, 2.72) and in overall functioning (GAF: treatment difference=3.0, 95% CI=-0.4, 6.4). CBD was well tolerated, and rates of adverse events were similar between the CBD and placebo groups. These results mean that CBD has beneficial effects in patients with schizophrenia and the effects do not depend on dopamine receptor antagonism that the other treatments rely on.
Greenwich biosciences has marketed CBD under the name Epidiolex, resulting in the 1st and only FDA-Approved Rx of CBD. Currently, it is approved to treat seizures associated with lennox-gastaut syndrome (LGS), Dravet syndrome, or tuberous sclerosis complex (TSC) in patients 1 year of age and older. Epidiolex is an oral solution of 100mg/ml and it is taken twice daily with meals. Even though CBD on its own is legal and sold over the counter, there are many benefits to having a prescription version. Since it is FDA approved, it undergoes strict regulation such as being grown without GMO, heavy metals, or pesticides, resulting in higher quality, safety, and efficacy of the drug. Additionally, the guidelines for CBD such as the quantity, grade, and precautions are clearly listed on the label, resulting in consistency and stability. Non-FDA approved CBD does not have to contain what might be on the label.
In conclusion, as the world transitions to breaking the stigma against parts of the marijuana plant. It is my hope that we continue to research the health benefits and provide better treatment to our patients.
References:
EPIDIOLEX® (cannabidiol). EPIDIOLEX.com. https://www.epidiolex.com/about-epidiolex. Accessed June 7, 2021.
Epidiolex(package insert). Carlsbad, CA. Greenwich Biosciences. 2020
McGuire P, Robson P, Cubala WJ, et al. Cannabidiol (CBD) as an Adjunctive Therapy in Schizophrenia: A Multicenter Randomized Controlled Trial. Am J Psychiatry. 2018;175(3):225-231. doi:10.1176/appi.ajp.2017.17030325
National Institute on Drug Abuse. Marijuana DrugFacts. National Institute on Drug Abuse. https://www.drugabuse.gov/publications/drugfacts/marijuana. Published June 4, 2021. Accessed June 7, 2021.
In the past few years, cannabidiol (CBD) has been gaining attention for its role in the treatment of skin disorders such as eczema, psoriasis, pruritus, and other inflammatory conditions. While there is more information on systemic CBD use in seizure disorders, not enough research and clinical studies have been conducted to fully support topical CBD use for skin conditions. CBD is the second most prevalent bioactive component of the Cannabis sativa (marijuana) plant and it does not produce the “high” associated with the delta‐9‐tetrahydrocannabinol (delta‐9‐THC) component of the marijuana plant. Unlike delta-9-THC, CBD does not alter sensory and time perception, an effect which has pushed most medical professionals to avoid using medicinal marijuana in their patients. CBD works by binding to cannabinoid (CB) receptors in the body, specifically CB1 receptors in the central nervous system (brain and spinal cord) and CB2 receptors in the peripheral nervous system (nerves in extremities), the digestive system, and the immune system. There is also research pointing at CB1 and CB2 receptors in the skin’s epidermal keratinocytes, cutaneous nerve fibers, melanocytes, sweat glands, hair follicles, and dermal cells. Another type of receptors that CBD may bind to are Transient Receptor Potential (TRP) receptors in certain types of skin cells that are involved in skin barrier maintenance, cell growth, cell differentiation, and inflammatory processes. More research needs to be conducted to determine the permeability of CBD into the skin after topical application and which vehicles may better facilitate this to produce more effective skin benefits. In eczema (or atopic dermatitis), CBD may modulate the inflammatory responses and hemp essential oil may have antimicrobial activity against Staphylococcus aureus bacteria that may contribute to dermatitis. For pruritus, research has indicated that the itch response is modulated through CB1 receptors in the central and peripheral nervous systems and TRP receptors, for which CBD may be useful in alleviating itch. There is also some anecdotal information for CBD use in treating psoriatic plaques which involve keratinocyte hyperproliferation and chronic inflammation. The full therapeutic potential and safety of CBD use in skin disorders is still unknown, but with a growing interest in CBD research, the future of CBD in more pharmaceutical products seems promising.
Works Cited:
White CM. A Review of Human Studies Assessing Cannabidiol's (CBD) Therapeutic Actions and Potential. J Clin Pharmacol. 2019;59(7):923-934. doi:10.1002/jcph.1387
Baswan SM, Klosner AE, Glynn K, et al. Therapeutic Potential of Cannabidiol (CBD) for Skin Health and Disorders. Clin Cosmet Investig Dermatol. 2020;13:927-942. Published 2020 Dec 8. doi:10.2147/CCID.S286411
Palmieri B, Laurino C, Vadalà M. A therapeutic effect of cbd-enriched ointment in inflammatory skin diseases and cutaneous scars. Clin Ter. 2019;170(2):e93-e99. doi:10.7417/CT.2019.2116
CBD stands for cannabidiol, derived from the hemp plant. Notably, hemp is not equivalent to marijuana although they are both derived from cannabis. Hemp grows up to 20 feet tall with long, sturdy stalks, and skinny leaves. It contains about 20% CBD and less than 0.3% THC; therefore, is non-psychoactive and federally legal. This is opposed to marijuana which grows up to just 5 feet tall with shorter and bushy, broad leaves. It contains less than 10% CBD and anywhere between 5 to 35% THC; therefore, is psychoactive and federally controlled.
Although most people just know about THC and CBD, major cannabinoids also include CBN, CBC, CBG, 2-AG, and anandamide. Most agonists only travel in one direction but cannabinoids can travel in both directions. This is known as the negative feedback loop.
See source 2: CBD exhibits many pharmacological properties and has been shown in vitro and in animal studies to possess anti-anxiety, anti-nausea, anti-arthritic, anti-epileptic, anti-psychotic, anti-inflammatory, neuroprotective and immunomodulatory properties. It has also shown potential in preclinical models of central nervous system diseases such as epilepsy, neurodegenerative diseases, schizophrenia, multiple sclerosis, affective disorders and the central modulation of feeding behavior. The pharmacologic effects of medical cannabis are dose-related and pharmacokinetic inter-patient variability should be taken into consideration. The individualization of dose is crucial in the achievement of maximum benefit.
Terpenes and flavonoids are essential to create an entourage effect where there is a greater efficacy when used in combination with cannabinoids. Examples include myrcene, pinene, caryophyllene, limonene, and terpinolene. Each has distinct smells and flavors that create unique experiences for medical cannabis users. They are natural from the plant and can be found in other ingredients as well. (Myrcene is calming, has an herbal smell, and can be found in hops, mango, and lemongrass.)
CBD oils have gained rapid popularity in mainstream culture for the numerous claims of medicinal effects when used by patients who are in need of cannabis therapy. CBD, or cannabinoid, oil is a low tetrahydrocannabinol product derived from Cannabis sativa, a class of hemp plant that has now been commercialized for its numerous potential uses. The use of CBD oil has gained mass popularity due to the fact that it can treat a wide plethora of possible conditions, including but not limited to chronic pain and anxiety, while also minimizing the intoxicating adverse effects patients often experience when using medical marijuana. While the use of CBD oil provides a promising outlook for patients who deal with chronic pain, it is extremely important to keep in mind that the field of CBD use is a rapidly evolving one with little regulation in place to ensure patient safety. An example of the flaws within the system would include the fact that many CBD products are mislabeled, showcasing incorrect CBD amounts in a product or misprinting certain ingredients.
Research has shown that the top four conditions in which CBD products are utilized are: chronic pain, multiple sclerosis, recurrent epilepsy, and for the treatment of nausea and vomiting. However, surveys have shown that the most effective use of CBD in the treatment for the stated conditions has occurred when the CBD is taken in conjunction with THC. Unlike THC, CBD is non-intoxicating when administered in a typical dosage amount. When using CBD for the treatment of chronic pain, the mechanism of action is assumed to be an interaction between the exogenous drug and the endocannabinoid system. By interacting with these receptors, the CBD is able to induce an anti-inflammatory response from the body. This body response is a wonderful way to combat chronic pain as the anti-inflammatory effect will lead to pain relief.
While CBD is still considered a Schedule I substance, products containing CBD are still sold without FDA regulation. Due to the lack of proper screening and oversight for products containing CBD, experts warn of safety concerns. Without proper regulation of what products are on the market, the labels may not accurately reflect what the product can provide. In addition, products may not have safe formulations. Many products that claim to contain CBD have been shown to not actually contain any of the CBD in question, resulting in products that yield zero effects when patients purchase and use them.
While CBD products have been used in conjunction with THC to provide relief for patients experiencing chronic pain, epilepsy, nausea and vomiting, and multiple sclerosis, the lack of proper surveillance for CBD products yields a market that can be hit or miss in terms of both efficacy and safety. CBD products should be examines carefully before being used and the results of such products should be assessed carefully to ensure proper patient safety. While the supposed benefits of CBD are proudly discussed, there is always a certain level of hesitance that must be exercised when utilizing products that are not regulated by the FDA.
Cannabis, derived from either the plant Cannabis Sativa or Cannabis Indica, contains at least 70 known cannabinoids. Δ-9-tetrahydrocannabinol (THC) is a high-affinity, partial agonist of cannabinoid type 1 receptor and is primarily responsible for the psychotropic effects of cannabis. Unlike THC, CBD is non-hedonic with no known abuse potential, lacks detectable psychoactive properties, and has a relatively low affinity for both cannabinoid type 1 receptor and cannabinoid type 2 receptor. Despite this, CBD has surprisingly high potency as an antagonist at both of these sites and in prior studies has been shown to counteract certain effects of THC when the two compounds were co-administered. In addition, CBD in animal studies has been shown to have anti-convulsant properties. However, the exact mechanism on how this occurs is not yet fully understood. The anti-convulsant properties may not be entirely explained by the effect of CBD on cannabinoid type 1 receptor and cannabinoid type 2 receptor and may be related in part to CBD-mediated modulation of the endocannabinoid system via inhibition of anandamide degradation. This would then result in decreased excess neuronal activity. A growing interest and need from patients, families, and physicians to better understand and regulate this product prompted the initiative to conduct several clinical trials to study CBD, ultimately manifesting in the FDA approval of Epidiolex, a new, 99% pure, oral CBD extract in June 2018. Three recent randomized, multi-center, double-blinded, placebo-controlled trials using Epidiolex have been conducted and published in two epileptic syndromes primarily of childhood. One Dravet and two Lennox–Gastaut syndromes. In patients with Dravet syndrome, a significant decrease in convulsive seizure frequency was seen in patients treated with Epidiolex when compared with placebo within the first month of the maintenance period ( P = 0.002). Similarly, for patients with Lennox–Gastaut syndrome, the addition of Epidiolex resulted in significant percentage decreases in drop seizures (atonic, tonic, or tonic-clonic) of 37.2% ( P = 0.002). However, randomized controlled studies in patients with Dravet or Lennox–Gastaut syndrome also demonstrated that more patients in the Epidiolex versus the placebo group had adverse events (84–94% for Epidiolex versus 69–75% for placebo across the three studies). The majority of all combined adverse events in patients receiving Epidiolex and placebo were considered mild to moderate in severity. Adverse events include, but are not limited to status epilepticus, somnolence, decreased appetite, diarrhea, vomiting, fatigue, and lethargy. In addition, increases in liver aminotransferase concentrations were seen in patients taking Epidiolex. In all such cases, liver enzyme levels either resolved after Epidiolex dose was decreased/stopped or the dose of another anti-seizure medication was decreased/stopped. Additionally, because no significant elevation of bilirubin was found, drug-induced liver injury was not seen. Although recent RCTs have already demonstrated significant improvement in seizure frequency with a relatively well-tolerated side effect profile, continued monitoring of Epidiolex is needed to further assess its long-term safety and efficacy, particularly in regards to its effects on the liver.
References
Sekar K, Pack A. Epidiolex as adjunct therapy for treatment of refractory epilepsy: a comprehensive review with a focus on adverse effects. F1000Res. 2019;8
Cannabis sativa is a plant native to central and western Asian and contains over 400 chemical compounds and about 80 are biologically active. Tetrahydrocannabinol is psychoactive whereas cannabidiol or CBD doesn’t have psychoactive activity. Cannabidiol acts as an agonist and antagonist activity of CB1 and CB2 receptors, which are G-protein coupled receptors. It is also a partial agonist of serotonin 5-HT1A receptor. CBD is used for numerous beneficial pharmacologic effects including analgesic and anti-inflammatory actions due to inhibition of cyclooxygenase and lipoxygenase. As of right now, FDA has approved CBD for the treatment of seizures from Lennox-Gastaut syndrome and Dravet syndrome in patients two years and older. Adverse effects include dose related liver damage and it is essential to monitor bilirubin and transaminase levels as well as liver enzymes before and during treatment. Concomitant use with other medications like leflunomide and valproate can worsen liver damage. Other adverse effects are somnolence, sedation, increased suicidal thoughts and behavior. Currently, there are clinical studies being done to investigate the use of CBD in anxiety, chronic pain, anti-inflammatory diseases and neurodegenerative diseases. In a study done in patients with Parkison’s, they were started with 5 mg/kg/day of Epidiolex, which is a CBD formulation. Then, the dose was increased by 2.5-5 mg/kg at 3-5 days intervals until they reached 20 mg/kg/day. It was found that in the 10 patients, they had improvements in cognition and depression associated with Parkison’s disease. There were also some side effects observed with the use of CBD including diarrhea, fatigue and increased liver enzyme levels.
References
Meissner H, Cascella M. Cannabidiol (CBD) [Updated 2020 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556048/
Pauli CS, Conroy M, Vanden Heuvel BD, Park SH. Cannabidiol Drugs Clinical Trial Outcomes and Adverse Effects. Front Pharmacol. 2020;11:63. Published 2020 Feb 25. doi:10.3389/fphar.2020.00063
Cannabidiol (CBD) is increasingly becoming part of therapeutic treatments as it has demonstrated uses in neurological, rheumatological, and immunologic practices. It had to overcome the stigma of being chemically related to marijuana - a psychoactive drug that is still illegal in most parts of the United States. There are still many unanswered questions about CBD because its pharmacological mechanisms of action are not well understood and long term studies of its chronic use are either still in progress or have not been conducted yet.
Although the serotonin system is involved in complex physiological processes, current therapies attempt to alter levels of serotonin to treat a wide range of neurological conditions. CBD is thought to activate the 5-HT1A serotonin receptors, which are in-part responsible for modulating the anxiety, addiction, depression, sexual dysfunction, psychotic behavior pathways. Current guidelines have not included CBD as therapeutic options for these disease states.
CBD has shown to provide analgesia in chronic or resistant neuropathic, rheumatological, and cancer pain. For years, it was assumed to act at the cannabinoid (CB) receptors, which help modulate the sensation of pain. However, it was discovered to have little to no affinity to the CB receptors. The current working theory is that CBD acts on multiple pain pathways like serotonin (e.g., 5-HT1A), opioid, transient receptor potential cation channels (TRPV), and peroxisome proliferator-activated receptors (PPAR).
The PPARs may play some part in the pain pathway but are also responsible for lipid uptake, energy metabolism, and inflammation. Interestingly, PPAR-gamma is involved in anti-proliferation of tumor growth in lung cancer cells and the degradation of amyloid-beta plaques typically found in Alzheimer’s patients.
The Food and Drug Administration (FDA) holds purview over all cannabis products, whether it is derived from cannabidiol or tetrahydrocannabinol (THC). It is currently illegal for manufacturers to add CBD to over-the-counter medications, dietary supplements, or food. The only FDA-approved CBD product is Epidiolex oral solution for the treatment of seizures associated with two rare and severe forms of epilepsy. It shouldn’t be confused with other cannabis-related drug products: Marinol (dronabinol) oral capsule, Syndros (dronabinol) oral solution, and Cesamet (nabilone) oral capsule. These products are THC products approved by the FDA for use in chemotherapy-induced nausea and vomiting. However, in 2018, the Farm Bill federally legalized hemp products containing no more than 0.3% THC. Though it was federally legalized, states were allowed to create their individual policies.
References
How CBD Works. Project CBD: How to Use CBD & Cannabis. https://www.projectcbd.org/science/how-cbd-works. Accessed July 2, 2020.
Crippa JA, Guimarães FS, Campos AC, Zuardi AW. Translational Investigation of the Therapeutic Potential of Cannabidiol (CBD): Toward a New Age. Frontiers in Immunology. 2018;9. doi:10.3389/fimmu.2018.02009
Bih CI, Chen T, Nunn AVW, Bazelot M, Dallas M, Whalley BJ. Molecular Targets of Cannabidiol in Neurological Disorders. Neurotherapeutics. 2015;12(4):699-730. doi:10.1007/s13311-015-0377-3
Russo E. Cannabinoids in the management of difficult to treat pain. Therapeutics and Clinical Risk Management. 2008;Volume 4:245-259. doi:10.2147/tcrm.s1928
CBD otherwise known as cannabidiol is an active ingredient of cannabis and is naturally occurring from the cannabis plant. CBD is being tested all around the world for its therapeutic properties as a safe and non-addictive substance. CBD is a close relative of THC (tetrahydrocannabinol), which is known to cause the “high” usually associated with marijuana. Although both CBD and THC have been tested for its therapeutic properties, CBD does not cause the high/stoned/intoxicated state that THC does as it binds to different receptors in the brain. CBD can actually be used to neutralize the effects of THC, depending on how much of each compound is used.
CBD is being sought out as an alternative method of treatment in comparison to pharmaceutical agents with harsh side effects. This can be used as an aid in relief to chronic pain, anxiety, inflammation, depression, and other conditions. There are a wide range of diseases in which CBD is thought to be beneficial such as: autoimmune diseases (inflammation, rheumatoid arthritis), neurological conditions (Alzheimer’s, dementia, Parkinson’s, multiple sclerosis, epilepsy, Huntington’s chorea, stroke, traumatic brain injury), metabolic syndrome (diabetes, obesity), neuropsychiatric illness (autism, ADHD, PTSD, alcoholism), gut disorders (colitis, Chron’s), cardiovascular dysfunction (atherosclerosis, arrhythmia), and skin disease (acne, dermatitis, psoriasis). As mentioned in the PowerPoint provided, a new medication has recently come into the market for treatment of seizures known as Epidiolex, and the main component of this medication is cannabidiol oil.
Epidiolex is a prescription cannabidiol oil used in Lennox-Gastaut Syndrome and Dravet Syndrome. The product may be prescribed to those aged two or older, to patients who have either Lennox-Gastaut Syndrome or Dravet Syndrome seizure disorders, and have failed multiple seizure medications/therapies. Epidiolex is the only FDA approved product containing CBD for prescription purposes, in treatment of two rare seizures. As Epidiolex is the only FDA approved product on the market, there are various products on the market advertised as oils, topicals, capsules, vaping products, etc. to make CBD more readily available to the public for those who are unable to receive the prescription. Though there seem to be many benefits to CBD, many prescribers are not using Epidiolex off-label as it is very costly and not affordable, especially to those who don’t have access to health insurance. Those who purchase CBD oil or CBD based products for relief of chronic pain, anxiety, etc., should also be aware that since these products are unregulated by the FDA, the dose may be listed on the product, but it is not fully aware if one would be receiving that dose or something higher/lower. Essentially, the buyer is unaware of what they are receiving. CBD can be a helpful alternative without all the side effects of prescription medications and is becoming more prevalent on the market, but as there is limited data and studies being provided, the capacity of CBD is not fully aware, and should be discussed with a medical personnel before starting up the use of the product.
The topic of Cannabis seems very controversial whether it be for recreational or
medicinal purposes. CBD oil is making its way into headlines and being incorporated into a variety of products from lip balms, to skincare, to vitamins. The source is especially important because although people believe it is from the cannabis plant, the products marketed today are extracted from the plant hemp. The two sources of cannabis are from either sativa or indica. Cannabis indica has larger amounts of Cannabidiol or CBD and is known for relaxation, to reduce inflammation and to reduce intra-ocular pressure (for glaucoma). Cannabis sativa has larger amounts of Tetrahydrocannabinol or THC and is known to be more energizing, used for headaches, pain and nausea and stimulates appetite. CBD is known to not give the high that THC products have since it is not a psychotomimetic compound. Traditional medicinal marijuana can have many positive benefits, like reducing anxiety, relieving pain, and treating inflammation. It can also help with treatment of cough, cramps, insomnia, arthritis, gout, epilepsy, and even venereal disease. It is especially used to cure the nausea and vomiting associated with chemotherapy. Nonetheless, research about the effects of CBD oil for topical use is still underway. Many areas of dermatology from acne, to psoriasis, to inflammation, to pruritis, to skin cancer can be treated with cannabinoids. A type of endogenous cannabinoid AEA or arachidonoylethanolamide can induce lipid production in sebaceous glands at low levels but also induce apoptosis at higher levels. Since the leading cause of acne is overproduction of sebum, AEA can then decrease the appearance of acne. According to the Journal of Immunology, cannabinoids can also alleviate inflammation characteristics of allergic dermatitis. Because of CBD’s ability to heal inflammation and oil production, it can be the ideal combination for acne treatment. However, caution still needs to be taken when using products that are not FDA approved which may or may not be labeled correctly.
SBIRT Clinical Guidance Resources Marijuana web. Accessed May 21, 2020
Pertwee RG. Targeting the endocannabinoid system with cannabinoid receptor agonists: pharmacological strategies and therapeutic possibilities. Philos Trans R Soc Lond B Biol Sci. 2012;367(1607):3353-3363.
Cannabidiol (CBD) is a natural occurring compound in found in the cannabis plant. It is closely related to another compound known as THC. Both CBD and THC are classified as phytocannabinoids and share similar health benefits. However, THC produces the “high” associated with marijuana use while CBD is non-psychoactive and non-addictive.
CBD is not the same as marijuana; CMD is a single compound in the cannabis plant while marijuana is a type of cannabis plant that contains many naturally occurring compounds including CBD and THC.
The PowerPoint went over the mechanism behind CBD. While the exact mechanism of action is unclear, it is known to act on the cannabinoid (CB) receptors of the endocannabinoid system, which are present throughout the body. CBD is also a negative allosteric modulator of CB1 receptors, allowing it to inhibit psychomimetic effects.
While there are many CBD products available on the market, Epidiolex is the only one that is FDA-approved. It is indicated for two rare, severe forms of epilepsy: Lennox-Gastaut syndrome and Dravet syndrome. There are ongoing studies for test efficacy in treating other diseases including Parkinson’s, schizophrenia, anxiety, and arthritis.
Next, the PowerPoint discussed the safety of CBD. CBD is relatively well tolerated. Common side effects include decreased appetite, diarrhea, somnolence, fatigue, and rash. Patients on CBD should be monitored for drug interactions with other hepatotoxic drugs, sedatives, and herbs or supplements.
In conclusion, while CBD is becoming a popular, mainstream product with promising health benefits, there is still limited data on its safety and efficacy. Further studies are needed before CBD can be taken for any reason. Patients also need to be aware that some CBD products are being marketed with unproven medical claims and are not regulated by the FDA.
Reference:
What to Know About Products Containing Cannabis and CBD. U.S. Food and Drug Administration. https://www.fda.gov/consumers/consumer-updates/what-you-need-know-and-what-were-working-find-out-about-products-containing-cannabis-or-cannabis. Accessed May 21, 2020.
This powerpoint summarized the different CBD products and the medical uses of these products. Cannabidiol (CBD) is one of the active ingredients of cannabis more commonly known as marijuana. CBD is directly derived from the hemp plant. CBD is considered non-psychoactive and non addictive. How does CBD work? CBD has little binding affinity for either of the two cannabinoid receptors, CB1 and CB2. However, it acts on other receptors and ion channels to produce its medical therapeutic effects. It activates the serotonin receptor (5HT1A) when used in high doses, which helps produce an anti-anxiety effect. It also acts on the Villanoid receptors. It acts on the TRPV1 receptor, which functions as an ion channel and it is known to mediate pain perception, inflammation, and body temperature. Although there are many more receptors it interacts with, these are some of the ways CBD provides its functional effects. Epidiolex is a prescription CBD product which is indicated for Lennox-Gastaut Syndrome or Dravet Syndrome in patients 2 years of age and older. Other products include a massage candle to help moisturize skin, a spray, soothing serum to help with discomfort, CBD oil to help with anxiety, and many more. CBD products are being studied for parkinsons, schizophrenia, insomnia, arthritis, etc. Some side effects that patients can experience when using CBD products are decreased appetite, diarrhea, fatigue, rash, etc. Although this product has many benefits, there aren't any FDA regulations on them, which makes it harder for pharmacists to recommend these products to patients. The only product that is FDA approved is the Epidiolex. As a pharmacist, if a patient is using CBD products and they make you aware of it, it is very important to screen for drug-drug interactions with their prescription medications, especially the sedative medications or any over the counter or herbal supplements they might be taking to ensure they are using this safely. CBD products also can cause liver injury, which is something patients should be aware of if they have a past history of liver disease.
Reference:
How CBD Works. Project CBD: Medical Marijuana & Cannabinoid Science. https://www.projectcbd.org/science/how-cbd-works. Accessed May 21, 2020.
Cannabidiol (CBD) has gained significant popularity in recent years for its therapeutic properties. Derived from the cannabis plant, CBD is distinguished as a non-addictive substance, unlike its counterpart tetrahydrocannabinol (THC), which is also found in cannabis and is known for its therapeutic benefits but is addictive.
CBD exerts its effects by mimicking the actions of endogenous cannabinoids within the body's endocannabinoid system. This system comprises CB1 receptors primarily located in the brain and central nervous system, and CB2 receptors found in peripheral organs, particularly those involved with the immune system. By interacting with these receptors, CBD can offer therapeutic relief for conditions such as anxiety, chronic pain, insomnia, and various other ailments. It has also demonstrated potential in alleviating nerve pain and exhibiting anti-cancer properties.
The efficacy of CBD products lies in their ability to influence the endocannabinoid system, which regulates numerous physiological processes including mood, energy levels, immune function, pain perception, and stress response. Disruptions in this system can impact the progression of various diseases, making CBD a versatile treatment option.
CBD products come in various forms including oils, lotions, capsules, and more, offering alternatives to traditional medications with potentially fewer side effects. However, despite its natural origins, there are misconceptions surrounding CBD. It is often wrongly perceived as the beneficial component of cannabis while THC is seen negatively due to its psychoactive effects and potential for abuse. Both compounds, when used appropriately and in controlled doses, can offer therapeutic benefits. It's crucial to note that while many CBD products are available over-the-counter, they are not regulated by the FDA for safety and efficacy. The FDA warns against mislabeling and unsubstantiated medical claims associated with CBD products, emphasizing the importance of using them as directed.
Epidiolex stands as the sole FDA-approved CBD product, specifically prescribed since 2018 for treating seizures associated with Lennox-Gastaut syndrome, Dravet syndrome, and tuberous sclerosis complex in pediatric patients aged one year and older. Initially classified as a Schedule I drug (reserved for substances with high abuse potential and no recognized medical use), Epidiolex was later reclassified to Schedule V following extensive research demonstrating its therapeutic benefits and minimal risk of abuse. It is administered orally as a solution with a concentration of 100 mg/mL, with dosing adjusted based on the specific condition and patient's response, while hepatic function monitoring is essential due to potential liver-related side effects.
While CBD offers natural advantages, its consumption should be approached with caution regarding potential adverse effects. Natural does not equate to completely safe, and proper dosage adherence is essential to mitigate risks associated with its use. Understanding these nuances ensures that individuals can safely harness the therapeutic benefits of CBD while minimizing potential drawbacks.
Rapin, L., Gamaoun, R., El Hage, C., Arboleda, M. F., & Prosk, E. (2021). Cannabidiol use and effectiveness: real-world evidence from a Canadian medical cannabis clinic. Journal of cannabis research, 3(1), 19. https://doi.org/10.1186/s42238-021-00078-w
Iffland, K., & Grotenhermen, F. (2017). An Update on Safety and Side Effects of Cannabidiol: A Review of Clinical Data and Relevant Animal Studies. Cannabis and cannabinoid research, 2(1), 139–154. https://doi.org/10.1089/can.2016.0034
Cannabidiol has surged in popularity in recent years, emerging as a key player in the health and wellness industry. As an active compound derived from the cannabis plant, CBD offers a range of potential health benefits, leading to its widespread adoption in pharmacy settings. CBD is primarily known for its potential therapeutic effects, which have led to its use in various pharmacy products. One of the most common uses of CBD is in the treatment of chronic pain, with studies suggesting that it may help alleviate pain associated with conditions such as arthritis and multiple sclerosis. Another key use of CBD in pharmacy is in the management of anxiety and depression. Research has shown that CBD may have anxiolytic and antidepressant effects, making it a potentially valuable addition to the treatment options available for these conditions. In addition to pain and mental health disorders, CBD is also being studied for its potential role in treating other health issues, including epilepsy, acne, and neurodegenerative disorders such as Alzheimer's disease.
One of the key benefits of CBD in pharmacy is its perceived safety profile. Unlike tetrahydrocannabinol (THC), another compound found in cannabis, CBD is not psychoactive, meaning it does not produce the "high" typically associated with cannabis use. This makes CBD a more appealing option for many patients seeking natural alternatives to traditional pharmaceuticals. CBD is generally well-tolerated, with few reported side effects. This makes it a potentially attractive option for patients who may not tolerate the side effects of traditional medications. While CBD is generally considered safe, it is not without risks. Some studies have suggested that high doses of CBD may cause liver toxicity in animals. CBD can interact with certain medications, potentially affecting their efficacy. It is important for pharmacists to be aware of these potential interactions and advise patients accordingly.
In conclusion, CBD has emerged as a popular and potentially beneficial addition to pharmacy products. While more research is needed to fully understand its effects, CBD shows promise as a natural alternative for a range of health issues. Pharmacists play a crucial role in educating patients about the uses, benefits, and risks of CBD, helping them make informed decisions about their health and wellness.
References
Pamplona, F. A., da Silva, L. R., & Coan, A. C. (2018). Potential clinical benefits of CBD-rich cannabis extracts over purified CBD in treatment-resistant epilepsy: observational data meta-analysis. Frontiers in Neurology, 9, 759.
Blessing, E. M., Steenkamp, M. M., Manzanares, J., & Marmar, C. R. (2015). Cannabidiol as a potential treatment for anxiety disorders. Neurotherapeutics, 12(4), 825-836.
Palmieri, B., Laurino, C., & Vadalà, M. (2019). A therapeutic effect of cbd-enriched ointment in inflammatory skin diseases and cutaneous scars. Clinical Therapeutics, 170(4), e230-e237.
Iffland, K., & Grotenhermen, F. (2017). An update on safety and side effects of cannabidiol: a review of clinical data and relevant animal studies. Cannabis and Cannabinoid Research, 2(1), 139-154.
CBD for Pain Written by Justin Ayob and Antonio Ortega Cannabidiol (CBD) is a nonintoxicating Phyto cannabinoid extracted from Cannabis sativa, primarily found in the flowers and leaves of the cannabis plant. Of the many cannabinoids present in Cannabis, Δ9tetrahydrocannabinol (Δ9-THC) and cannabidiol are the two components found at the highest concentrations. In recent years Cannabidiol’s availability has increased as more changes are being made to federal and state regulations across the country. With legislative action taking place, the market for CBD as a sole agent, as opposed to in combination with THC in medical marijuana) is rapidly expanding. CBD marketed products such as gummies, body lotions, oils for oral ingestion, and even cartridges for vaping are now being stocked at pharmacies in many states. The anterolateral system where pain perception and modulation are mediated, include nociceptors that signal and give rise to acute pain. Tissue damage that leads to inflammation mediates chronic pain known as inflammatory nociceptive pain. CBD regulates the endocannabinoid system which is present at essentially all levels of the anterolateral system and seems to play an unknown role in immunoinflammatory responses. As of today, there is not enough clinical data to support CBD as a sole agent in the treatment of pain. According to multiple clinical trials CBD has been shown to be well tolerated in children with seizure disorders, but its safety profile in adults with chronic health conditions remain unknown. Of at least 19 registered clinical trials evaluating CBD’s effect on pain, most have not begun recruiting trial candidates while others have not listed clinical trial results. While CBD continues to grow in popularity in the states and many have reported varying benefits to the use of CBD it is important to remember as pharmacists to inform patients that there is insufficient evidence to knowingly recommend the use of CBD for pain management. References:
· Mlost, Jakub et al. “Cannabidiol for Pain Treatment: Focus on Pharmacology and Mechanism of Action.” International journal of molecular sciences vol. 21,22 8870. 23 Nov. 2020, doi:10.3390/ijms21228870
· Svensson, Craig K. “CBD for the treatment of pain: What is the evidence?.” Journal of the American Pharmacists Association : JAPhAvol. 60,6 (2020): e80-e83. doi:10.1016/j.japh.2020.06.009
Cannabidiol:
Written By: Natalia Loomis
Marijuana refers to the dried leaves, flowers, stems, and seeds from the cannabis sativa or cannabis indica plant. When it comes to this plant, most people think of stoners, Woodstock, hallucinations, and getting high. There is way more to this plant, what people with the stigmas against marijuana is just THC (the cannabinoid responsible for the “high effect”) Moreover, there are many other cannabinoids found in marijuana including cannabidiol (CBD). CBD is the second most prevalent active ingredient in cannabis which does not exhibit any “high” effects.
CBD has grown in popularity recently and has been tested in various countries for its therapeutic properties. CBD is being researched and marketed as an alternative method of treatment to certain pharmaceutical agents that contain harsh side effects. This can be used as an aid in relief to chronic pain, anxiety, inflammation, depression, and other conditions. There are a wide range of diseases in which CBD is thought to be beneficial such as: autoimmune diseases (inflammation, rheumatoid arthritis), neurological conditions (Alzheimer’s, dementia, Parkinson’s, multiple sclerosis, epilepsy, Huntington’s chorea, traumatic brain injury), metabolic syndrome (diabetes, obesity), neuropsychiatric illness (autism, ADHD, PTSD, alcoholism), gut disorders (colitis, Chron’s), cardiovascular dysfunction (atherosclerosis, arrhythmia), and skin disease (acne, dermatitis, psoriasis).
In a double blind multi-centered controlled trial, patients with schizophrenia were randomized in a 1:1 ratio to receive CBD (1000 mg/day; N=43) or placebo (N=45) alongside their existing antipsychotic medication. Participants were assessed before and after treatment using the Positive and Negative Syndrome Scale (PANSS), the Brief Assessment of Cognition in Schizophrenia (BACS), the Global Assessment of Functioning scale (GAF), and the improvement and severity scales of the Clinical Global Impressions Scale (CGI-I and CGI-S). After 6 weeks of treatment, compared with the placebo group, the CBD group had lower levels of positive psychotic symptoms (PANSS: treatment difference=-1.4, 95% CI=-2.5, -0.2) and were more likely to have been rated as improved (CGI-I: treatment difference=-0.5, 95% CI=-0.8, -0.1) and as not severely unwell (CGI-S: treatment difference=-0.3, 95% CI=-0.5, 0.0) by the treating clinician. Patients who received CBD also showed greater improvements that fell short of statistical significance in cognitive performance (BACS: treatment difference=1.31, 95% CI=-0.10, 2.72) and in overall functioning (GAF: treatment difference=3.0, 95% CI=-0.4, 6.4). CBD was well tolerated, and rates of adverse events were similar between the CBD and placebo groups. These results mean that CBD has beneficial effects in patients with schizophrenia and the effects do not depend on dopamine receptor antagonism that the other treatments rely on.
Greenwich biosciences has marketed CBD under the name Epidiolex, resulting in the 1st and only FDA-Approved Rx of CBD. Currently, it is approved to treat seizures associated with lennox-gastaut syndrome (LGS), Dravet syndrome, or tuberous sclerosis complex (TSC) in patients 1 year of age and older. Epidiolex is an oral solution of 100mg/ml and it is taken twice daily with meals. Even though CBD on its own is legal and sold over the counter, there are many benefits to having a prescription version. Since it is FDA approved, it undergoes strict regulation such as being grown without GMO, heavy metals, or pesticides, resulting in higher quality, safety, and efficacy of the drug. Additionally, the guidelines for CBD such as the quantity, grade, and precautions are clearly listed on the label, resulting in consistency and stability. Non-FDA approved CBD does not have to contain what might be on the label.
In conclusion, as the world transitions to breaking the stigma against parts of the marijuana plant. It is my hope that we continue to research the health benefits and provide better treatment to our patients.
References:
EPIDIOLEX® (cannabidiol). EPIDIOLEX.com. https://www.epidiolex.com/about-epidiolex. Accessed June 7, 2021.
Epidiolex(package insert). Carlsbad, CA. Greenwich Biosciences. 2020
McGuire P, Robson P, Cubala WJ, et al. Cannabidiol (CBD) as an Adjunctive Therapy in Schizophrenia: A Multicenter Randomized Controlled Trial. Am J Psychiatry. 2018;175(3):225-231. doi:10.1176/appi.ajp.2017.17030325
National Institute on Drug Abuse. Marijuana DrugFacts. National Institute on Drug Abuse. https://www.drugabuse.gov/publications/drugfacts/marijuana. Published June 4, 2021. Accessed June 7, 2021.
Prior to the 19th century, little was known about epilepsy despite it being one of the most common neurological disorders. In 2015, 1.2% of Americans had active epilepsy. This is estimated to be roughly 3.4 million people with active epilepsy in the United States of America. Epilepsy is defined as a disorder of recurrent seizures. Roughly 125,000 people in the US are diagnosed w/ epilepsy every year. Roughly 30% are younger than 18 y/o at diagnosis. Around 5% of the world population experiences at least one lifetime seizure. 30-40% of patients continue to seize despite using anti-epileptic drugs (AED). The majority of patients complain of drowsiness or difficulty in concentration with his or her current therapy.
A patient is considered to have epilepsy when she or he has had two or more unprovoked seizures (with or without convulsions). The clinical definition of a seizure is the clinical manifestations or symptoms of disturbed electrical activity.
International League Against Epilepsy (ILAE) classified
epilepsy according to category, defined by onset
features, and etiology. The two major categories of epilepsy are- 1. Generalized- absence, tonic-clonic, myoclonic and 2. Partial- simple partial seizures (patient has no loss of consciousness), complex partial seizures (patient has loss of consciousness). Non-pharmacological options include a vagal nerve stimulator which is an implanted medical device, ketogenic diet, and/or surgery. I wasn’t aware of the ketogenic diet being a primary determinant in treating epilepsy so I am glad that I learned something completely new. More specifically, both the Modified Atkins Diet (MAD) and ketogenic diet are high fat and low carbohydrate diets that have been proven to reduce the number of seizures in both children and adults with epilepsy. Roughly half of the people who initiate and maintain these diet therapies will see over a 50% improvement in seizures. This must be done under supervision of a registered dietitian and in close coordination with the epilepsy physicians- as healthcare professionals it is crucial to be able to help people choose, initiate, and maintain the diets safely.
The very first and only FDA-approved medication containing cannabidiol is Epidiolex. As indicated on the package insert, Epidiolex is indicated for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients 2 years of age and older. The only dosage form it is available as is as an oral solution and the only strength available is as 100 milligrams per milliliter.
Lennox-Gastaut syndrome (LGS) is a rare type of epilepsy. Patients with LGS experience many different types of seizures including- 1. Tonic- stiffening of the body, 2. Atonic- temporary loss of muscle tone and consciousness, causing the patient to fall, 3. Atypical absence - staring episodes, and 4. Myoclonic- sudden muscle jerks. Dravet syndrome, also known as Severe Myoclonic Epilepsy of Infancy (SMEI), is also a rare form of epilepsy that is unfortunately very difficult to treat that begins in infancy and proceeds with morbidity that has a significant impact on individuals throughout their lifetime. Dravet syndrome has an estimated incidence rate of 1:15,700 individuals, 80% of whom have a mutation in their Sodium Voltage-Gated Channel Alpha Subunit 1 (SCN1A) gene. All in all, it is important that CBD can be implemented in medications for rare disorders and for many other disorders in general.
References-
Epidiolex. Package Insert. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/210365lbl.pdf
Patel, Anup. Medical Marijuana and Epilepsy. Epilepsy Foundation. https://www.epilepsy.com/learn/treating-seizures-and-epilepsy/other-treatment-approaches/medical-marijuana-and-epilepsy
Epilepsy Data and Statistics. Center of Disease Control and Prevention. https://www.cdc.gov/epilepsy/data/index.html
Lennox-Gaustat Syndrome. Cedars-Sinai. https://www.cedars-sinai.org/health-library/diseases-and-conditions/l/lennox-gastaut-syndrome.html
What Is Dravet Syndrome? Dravet Syndrome Foundation. https://www.dravetfoundation.org/what-is-dravet-syndrome/
Cannabidiol, also known as CBD, has been on the rise for the past few years. CBD provides many therapeutic effects. It originates from the cannabis plant and it is a non-addictive substance. CBD is often associated with tetrahydrocannabinol (THC) which is another component from the cannabis plant. THC is known for its therapeutic effect as well as its addictive effect on the body.
CBD works in our bodies by copying the effects of the body’s natural compound called endogenous cannabinoids which are part of the endocannabinoid system. The endocannabinoid system has two parts in which CBD can perform its therapeutic effect. CBD can work on CB1 receptors which are mainly found in the brains and central nervous system. CBD can also work on CB2 receptors which work on the peripheral organs especially those that work with the immune system.
CBD products are great alternatives that act as natural pain relievers from not only medication side effects but also for those who suffer from anxiety, chronic pain, lack of sleep, and other conditions. CBD has also been shown to help against nerve pain as well as have anti-cancer properties. The reason CBD products can have an effect on different diseases is because the endocannabinoid system functions by regulating different processes in our body such as our mood, energy level, immune activity, pain threshold, stress, and others. If the endocannabinoid system is disrupted then it can affect different disease progressions in the body.
CBD products come in different formulations such as oils, lotions, vitamins, roll-ons, capsules, and others. CBD products are effective but there are a few misconceptions that accompany the use of CBD. Many people associated CBD as being the good part of cannabis and THC as being the bad part of cannabis. Both CBD and THC have great therapeutic effects on the body if consumed in the correct doses. THC is not only for recreational purposes but people can abuse it when it is not used correctly. Although a lot of CBD products are sold over-the-counter, they do have protentional harmful side effects. CBD products are not approved by the food, Drug, and Administration Act (FDA) but the FDA does warn against any CBD products that are mislabeled and marketed with unproven medical claims. It is important to use CBD in the correctly labeled doses and to not exceed the limit. It does not mean because it is over-the-counter then it is safe to overuse.
There is only one FDA approved CBD product on the market that is a prescription drug. Epidiolex is a CBD product approved in 2018 and is used to treat seizures in pediatric population. The seizures it treats are associated with Lennox-Gastaut syndrome, Dravet syndrome, or tuberous sclerosis complex. It can be used in patients 1 year of age and older. Interestingly, Epidiolex used to be considered a schedule I drug which is a category for dangerous drugs such as heroin. Drugs in such category are not typically used. Later, once more CBD studies were made, the Drug Enforcement Administration (DEA) removed Epidiolex from Schedule I to Schedule V category. Schedule V is the least dangerous category for controlled medications under the Controlled Substances Act. Epidiolex comes as an oral solution with 100 mg/ mL The usual dosing for patients who have seizures associated with Lennox-Gastaut Syndrome or Dravet Syndrome is 2.5 mg/kg by mouth twice daily and it can be increased to a maintenance dose of 5 mg/kg twice daily after one week. The maximum dose a patient can be on for this medication is 10 mg/kg twice daily. The usual dosing for patients who have seizures associated with Tuberous Sclerosis Complex is also 2.5 mg/kg by mouth twice daily and it can be increased weekly by 2.5 mg/kg twice daily which a maximum recommended maintenance dose of 12.5 mg/kg twice daily. It is important to monitor hepatic function when taking this medication, therefore patients with liver damage need a dose adjustment when taking this medication.
CBD has great natural benefits on the body. Many people prefer it due to its natural properties but it is important to be mindful of its side effects. It does not mean because something is natural that it is safe to consume in large quantities.
“What Is CBD?” Definition of Cannabidiol & CBD Oil, www.projectcbd.org/about/what-cbd.
“CBD Misconceptions.” CBD Myths & Misconceptions, 2 Feb. 2019, www.projectcbd.org/cbd-101/cbd-misconceptions.
Commissioner, Office of the. “What to Know About Products Containing Cannabis and CBD.” U.S. Food and Drug Administration, FDA, www.fda.gov/consumers/consumer-updates/what-you-need-know-and-what-were-working-find-out-about-products-containing-cannabis-or-cannabis.
Epidiolex (Cannabinol) Oral Solution Prescribing Information, Oct. 2020.
Cannabidiol:
Marijuana refers to the dried leaves, flowers, stems, and seeds from the cannabis sativa or cannabis indica plant. When it comes to this plant, most people think of stoners, Woodstock, hallucinations, and getting high. There is way more to this plant, what people with the stigmas against marijuana is just THC (the cannabinoid responsible for the “high effect”) Moreover, there are many other cannabinoids found in marijuana including cannabidiol (CBD). CBD is the second most prevalent active ingredient in cannabis which does not exhibit any “high” effects.
CBD has grown in popularity recently and has been tested in various countries for its therapeutic properties. CBD is being researched and marketed as an alternative method of treatment to certain pharmaceutical agents that contain harsh side effects. This can be used as an aid in relief to chronic pain, anxiety, inflammation, depression, and other conditions. There are a wide range of diseases in which CBD is thought to be beneficial such as: autoimmune diseases (inflammation, rheumatoid arthritis), neurological conditions (Alzheimer’s, dementia, Parkinson’s, multiple sclerosis, epilepsy, Huntington’s chorea, traumatic brain injury), metabolic syndrome (diabetes, obesity), neuropsychiatric illness (autism, ADHD, PTSD, alcoholism), gut disorders (colitis, Chron’s), cardiovascular dysfunction (atherosclerosis, arrhythmia), and skin disease (acne, dermatitis, psoriasis).
In a double blind multicentered controlled trial, patients with schizophrenia were randomized in a 1:1 ratio to receive CBD (1000 mg/day; N=43) or placebo (N=45) alongside their existing antipsychotic medication. Participants were assessed before and after treatment using the Positive and Negative Syndrome Scale (PANSS), the Brief Assessment of Cognition in Schizophrenia (BACS), the Global Assessment of Functioning scale (GAF), and the improvement and severity scales of the Clinical Global Impressions Scale (CGI-I and CGI-S). After 6 weeks of treatment, compared with the placebo group, the CBD group had lower levels of positive psychotic symptoms (PANSS: treatment difference=-1.4, 95% CI=-2.5, -0.2) and were more likely to have been rated as improved (CGI-I: treatment difference=-0.5, 95% CI=-0.8, -0.1) and as not severely unwell (CGI-S: treatment difference=-0.3, 95% CI=-0.5, 0.0) by the treating clinician. Patients who received CBD also showed greater improvements that fell short of statistical significance in cognitive performance (BACS: treatment difference=1.31, 95% CI=-0.10, 2.72) and in overall functioning (GAF: treatment difference=3.0, 95% CI=-0.4, 6.4). CBD was well tolerated, and rates of adverse events were similar between the CBD and placebo groups. These results mean that CBD has beneficial effects in patients with schizophrenia and the effects do not depend on dopamine receptor antagonism that the other treatments rely on.
Greenwich biosciences has marketed CBD under the name Epidiolex, resulting in the 1st and only FDA-Approved Rx of CBD. Currently, it is approved to treat seizures associated with lennox-gastaut syndrome (LGS), Dravet syndrome, or tuberous sclerosis complex (TSC) in patients 1 year of age and older. Epidiolex is an oral solution of 100mg/ml and it is taken twice daily with meals. Even though CBD on its own is legal and sold over the counter, there are many benefits to having a prescription version. Since it is FDA approved, it undergoes strict regulation such as being grown without GMO, heavy metals, or pesticides, resulting in higher quality, safety, and efficacy of the drug. Additionally, the guidelines for CBD such as the quantity, grade, and precautions are clearly listed on the label, resulting in consistency and stability. Non-FDA approved CBD does not have to contain what might be on the label.
In conclusion, as the world transitions to breaking the stigma against parts of the marijuana plant. It is my hope that we continue to research the health benefits and provide better treatment to our patients.
References:
EPIDIOLEX® (cannabidiol). EPIDIOLEX.com. https://www.epidiolex.com/about-epidiolex. Accessed June 7, 2021.
Epidiolex(package insert). Carlsbad, CA. Greenwich Biosciences. 2020
McGuire P, Robson P, Cubala WJ, et al. Cannabidiol (CBD) as an Adjunctive Therapy in Schizophrenia: A Multicenter Randomized Controlled Trial. Am J Psychiatry. 2018;175(3):225-231. doi:10.1176/appi.ajp.2017.17030325
National Institute on Drug Abuse. Marijuana DrugFacts. National Institute on Drug Abuse. https://www.drugabuse.gov/publications/drugfacts/marijuana. Published June 4, 2021. Accessed June 7, 2021.
In the past few years, cannabidiol (CBD) has been gaining attention for its role in the treatment of skin disorders such as eczema, psoriasis, pruritus, and other inflammatory conditions. While there is more information on systemic CBD use in seizure disorders, not enough research and clinical studies have been conducted to fully support topical CBD use for skin conditions. CBD is the second most prevalent bioactive component of the Cannabis sativa (marijuana) plant and it does not produce the “high” associated with the delta‐9‐tetrahydrocannabinol (delta‐9‐THC) component of the marijuana plant. Unlike delta-9-THC, CBD does not alter sensory and time perception, an effect which has pushed most medical professionals to avoid using medicinal marijuana in their patients. CBD works by binding to cannabinoid (CB) receptors in the body, specifically CB1 receptors in the central nervous system (brain and spinal cord) and CB2 receptors in the peripheral nervous system (nerves in extremities), the digestive system, and the immune system. There is also research pointing at CB1 and CB2 receptors in the skin’s epidermal keratinocytes, cutaneous nerve fibers, melanocytes, sweat glands, hair follicles, and dermal cells. Another type of receptors that CBD may bind to are Transient Receptor Potential (TRP) receptors in certain types of skin cells that are involved in skin barrier maintenance, cell growth, cell differentiation, and inflammatory processes. More research needs to be conducted to determine the permeability of CBD into the skin after topical application and which vehicles may better facilitate this to produce more effective skin benefits. In eczema (or atopic dermatitis), CBD may modulate the inflammatory responses and hemp essential oil may have antimicrobial activity against Staphylococcus aureus bacteria that may contribute to dermatitis. For pruritus, research has indicated that the itch response is modulated through CB1 receptors in the central and peripheral nervous systems and TRP receptors, for which CBD may be useful in alleviating itch. There is also some anecdotal information for CBD use in treating psoriatic plaques which involve keratinocyte hyperproliferation and chronic inflammation. The full therapeutic potential and safety of CBD use in skin disorders is still unknown, but with a growing interest in CBD research, the future of CBD in more pharmaceutical products seems promising.
Works Cited:
White CM. A Review of Human Studies Assessing Cannabidiol's (CBD) Therapeutic Actions and Potential. J Clin Pharmacol. 2019;59(7):923-934. doi:10.1002/jcph.1387
Baswan SM, Klosner AE, Glynn K, et al. Therapeutic Potential of Cannabidiol (CBD) for Skin Health and Disorders. Clin Cosmet Investig Dermatol. 2020;13:927-942. Published 2020 Dec 8. doi:10.2147/CCID.S286411
Palmieri B, Laurino C, Vadalà M. A therapeutic effect of cbd-enriched ointment in inflammatory skin diseases and cutaneous scars. Clin Ter. 2019;170(2):e93-e99. doi:10.7417/CT.2019.2116
CBD stands for cannabidiol, derived from the hemp plant. Notably, hemp is not equivalent to marijuana although they are both derived from cannabis. Hemp grows up to 20 feet tall with long, sturdy stalks, and skinny leaves. It contains about 20% CBD and less than 0.3% THC; therefore, is non-psychoactive and federally legal. This is opposed to marijuana which grows up to just 5 feet tall with shorter and bushy, broad leaves. It contains less than 10% CBD and anywhere between 5 to 35% THC; therefore, is psychoactive and federally controlled.
Although most people just know about THC and CBD, major cannabinoids also include CBN, CBC, CBG, 2-AG, and anandamide. Most agonists only travel in one direction but cannabinoids can travel in both directions. This is known as the negative feedback loop.
See source 2: CBD exhibits many pharmacological properties and has been shown in vitro and in animal studies to possess anti-anxiety, anti-nausea, anti-arthritic, anti-epileptic, anti-psychotic, anti-inflammatory, neuroprotective and immunomodulatory properties. It has also shown potential in preclinical models of central nervous system diseases such as epilepsy, neurodegenerative diseases, schizophrenia, multiple sclerosis, affective disorders and the central modulation of feeding behavior. The pharmacologic effects of medical cannabis are dose-related and pharmacokinetic inter-patient variability should be taken into consideration. The individualization of dose is crucial in the achievement of maximum benefit.
Terpenes and flavonoids are essential to create an entourage effect where there is a greater efficacy when used in combination with cannabinoids. Examples include myrcene, pinene, caryophyllene, limonene, and terpinolene. Each has distinct smells and flavors that create unique experiences for medical cannabis users. They are natural from the plant and can be found in other ingredients as well. (Myrcene is calming, has an herbal smell, and can be found in hops, mango, and lemongrass.)
1. Cannabidiol (CBD) – what we know and what we don’t https://www.health.harvard.edu/blog/cannabidiol-cbd-what-we-know-and-what-we-dont-2018082414476
2. Curaleaf CBD Package Insert - https://curaleaf.com/wp-content/uploads/2021/pdf/PackageInsertCuraleafCBD.pdf
CBD oils have gained rapid popularity in mainstream culture for the numerous claims of medicinal effects when used by patients who are in need of cannabis therapy. CBD, or cannabinoid, oil is a low tetrahydrocannabinol product derived from Cannabis sativa, a class of hemp plant that has now been commercialized for its numerous potential uses. The use of CBD oil has gained mass popularity due to the fact that it can treat a wide plethora of possible conditions, including but not limited to chronic pain and anxiety, while also minimizing the intoxicating adverse effects patients often experience when using medical marijuana. While the use of CBD oil provides a promising outlook for patients who deal with chronic pain, it is extremely important to keep in mind that the field of CBD use is a rapidly evolving one with little regulation in place to ensure patient safety. An example of the flaws within the system would include the fact that many CBD products are mislabeled, showcasing incorrect CBD amounts in a product or misprinting certain ingredients.
Research has shown that the top four conditions in which CBD products are utilized are: chronic pain, multiple sclerosis, recurrent epilepsy, and for the treatment of nausea and vomiting. However, surveys have shown that the most effective use of CBD in the treatment for the stated conditions has occurred when the CBD is taken in conjunction with THC. Unlike THC, CBD is non-intoxicating when administered in a typical dosage amount. When using CBD for the treatment of chronic pain, the mechanism of action is assumed to be an interaction between the exogenous drug and the endocannabinoid system. By interacting with these receptors, the CBD is able to induce an anti-inflammatory response from the body. This body response is a wonderful way to combat chronic pain as the anti-inflammatory effect will lead to pain relief.
While CBD is still considered a Schedule I substance, products containing CBD are still sold without FDA regulation. Due to the lack of proper screening and oversight for products containing CBD, experts warn of safety concerns. Without proper regulation of what products are on the market, the labels may not accurately reflect what the product can provide. In addition, products may not have safe formulations. Many products that claim to contain CBD have been shown to not actually contain any of the CBD in question, resulting in products that yield zero effects when patients purchase and use them.
While CBD products have been used in conjunction with THC to provide relief for patients experiencing chronic pain, epilepsy, nausea and vomiting, and multiple sclerosis, the lack of proper surveillance for CBD products yields a market that can be hit or miss in terms of both efficacy and safety. CBD products should be examines carefully before being used and the results of such products should be assessed carefully to ensure proper patient safety. While the supposed benefits of CBD are proudly discussed, there is always a certain level of hesitance that must be exercised when utilizing products that are not regulated by the FDA.
References:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6154432/
https://pubmed.ncbi.nlm.nih.gov/31447137/
Cannabis, derived from either the plant Cannabis Sativa or Cannabis Indica, contains at least 70 known cannabinoids. Δ-9-tetrahydrocannabinol (THC) is a high-affinity, partial agonist of cannabinoid type 1 receptor and is primarily responsible for the psychotropic effects of cannabis. Unlike THC, CBD is non-hedonic with no known abuse potential, lacks detectable psychoactive properties, and has a relatively low affinity for both cannabinoid type 1 receptor and cannabinoid type 2 receptor. Despite this, CBD has surprisingly high potency as an antagonist at both of these sites and in prior studies has been shown to counteract certain effects of THC when the two compounds were co-administered. In addition, CBD in animal studies has been shown to have anti-convulsant properties. However, the exact mechanism on how this occurs is not yet fully understood. The anti-convulsant properties may not be entirely explained by the effect of CBD on cannabinoid type 1 receptor and cannabinoid type 2 receptor and may be related in part to CBD-mediated modulation of the endocannabinoid system via inhibition of anandamide degradation. This would then result in decreased excess neuronal activity. A growing interest and need from patients, families, and physicians to better understand and regulate this product prompted the initiative to conduct several clinical trials to study CBD, ultimately manifesting in the FDA approval of Epidiolex, a new, 99% pure, oral CBD extract in June 2018. Three recent randomized, multi-center, double-blinded, placebo-controlled trials using Epidiolex have been conducted and published in two epileptic syndromes primarily of childhood. One Dravet and two Lennox–Gastaut syndromes. In patients with Dravet syndrome, a significant decrease in convulsive seizure frequency was seen in patients treated with Epidiolex when compared with placebo within the first month of the maintenance period ( P = 0.002). Similarly, for patients with Lennox–Gastaut syndrome, the addition of Epidiolex resulted in significant percentage decreases in drop seizures (atonic, tonic, or tonic-clonic) of 37.2% ( P = 0.002). However, randomized controlled studies in patients with Dravet or Lennox–Gastaut syndrome also demonstrated that more patients in the Epidiolex versus the placebo group had adverse events (84–94% for Epidiolex versus 69–75% for placebo across the three studies). The majority of all combined adverse events in patients receiving Epidiolex and placebo were considered mild to moderate in severity. Adverse events include, but are not limited to status epilepticus, somnolence, decreased appetite, diarrhea, vomiting, fatigue, and lethargy. In addition, increases in liver aminotransferase concentrations were seen in patients taking Epidiolex. In all such cases, liver enzyme levels either resolved after Epidiolex dose was decreased/stopped or the dose of another anti-seizure medication was decreased/stopped. Additionally, because no significant elevation of bilirubin was found, drug-induced liver injury was not seen. Although recent RCTs have already demonstrated significant improvement in seizure frequency with a relatively well-tolerated side effect profile, continued monitoring of Epidiolex is needed to further assess its long-term safety and efficacy, particularly in regards to its effects on the liver.
References
Sekar K, Pack A. Epidiolex as adjunct therapy for treatment of refractory epilepsy: a comprehensive review with a focus on adverse effects. F1000Res. 2019;8
Cannabis sativa is a plant native to central and western Asian and contains over 400 chemical compounds and about 80 are biologically active. Tetrahydrocannabinol is psychoactive whereas cannabidiol or CBD doesn’t have psychoactive activity. Cannabidiol acts as an agonist and antagonist activity of CB1 and CB2 receptors, which are G-protein coupled receptors. It is also a partial agonist of serotonin 5-HT1A receptor. CBD is used for numerous beneficial pharmacologic effects including analgesic and anti-inflammatory actions due to inhibition of cyclooxygenase and lipoxygenase. As of right now, FDA has approved CBD for the treatment of seizures from Lennox-Gastaut syndrome and Dravet syndrome in patients two years and older. Adverse effects include dose related liver damage and it is essential to monitor bilirubin and transaminase levels as well as liver enzymes before and during treatment. Concomitant use with other medications like leflunomide and valproate can worsen liver damage. Other adverse effects are somnolence, sedation, increased suicidal thoughts and behavior. Currently, there are clinical studies being done to investigate the use of CBD in anxiety, chronic pain, anti-inflammatory diseases and neurodegenerative diseases. In a study done in patients with Parkison’s, they were started with 5 mg/kg/day of Epidiolex, which is a CBD formulation. Then, the dose was increased by 2.5-5 mg/kg at 3-5 days intervals until they reached 20 mg/kg/day. It was found that in the 10 patients, they had improvements in cognition and depression associated with Parkison’s disease. There were also some side effects observed with the use of CBD including diarrhea, fatigue and increased liver enzyme levels.
References
Meissner H, Cascella M. Cannabidiol (CBD) [Updated 2020 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK556048/
Pauli CS, Conroy M, Vanden Heuvel BD, Park SH. Cannabidiol Drugs Clinical Trial Outcomes and Adverse Effects. Front Pharmacol. 2020;11:63. Published 2020 Feb 25. doi:10.3389/fphar.2020.00063
Cannabidiol (CBD) is increasingly becoming part of therapeutic treatments as it has demonstrated uses in neurological, rheumatological, and immunologic practices. It had to overcome the stigma of being chemically related to marijuana - a psychoactive drug that is still illegal in most parts of the United States. There are still many unanswered questions about CBD because its pharmacological mechanisms of action are not well understood and long term studies of its chronic use are either still in progress or have not been conducted yet.
Although the serotonin system is involved in complex physiological processes, current therapies attempt to alter levels of serotonin to treat a wide range of neurological conditions. CBD is thought to activate the 5-HT1A serotonin receptors, which are in-part responsible for modulating the anxiety, addiction, depression, sexual dysfunction, psychotic behavior pathways. Current guidelines have not included CBD as therapeutic options for these disease states.
CBD has shown to provide analgesia in chronic or resistant neuropathic, rheumatological, and cancer pain. For years, it was assumed to act at the cannabinoid (CB) receptors, which help modulate the sensation of pain. However, it was discovered to have little to no affinity to the CB receptors. The current working theory is that CBD acts on multiple pain pathways like serotonin (e.g., 5-HT1A), opioid, transient receptor potential cation channels (TRPV), and peroxisome proliferator-activated receptors (PPAR).
The PPARs may play some part in the pain pathway but are also responsible for lipid uptake, energy metabolism, and inflammation. Interestingly, PPAR-gamma is involved in anti-proliferation of tumor growth in lung cancer cells and the degradation of amyloid-beta plaques typically found in Alzheimer’s patients.
The Food and Drug Administration (FDA) holds purview over all cannabis products, whether it is derived from cannabidiol or tetrahydrocannabinol (THC). It is currently illegal for manufacturers to add CBD to over-the-counter medications, dietary supplements, or food. The only FDA-approved CBD product is Epidiolex oral solution for the treatment of seizures associated with two rare and severe forms of epilepsy. It shouldn’t be confused with other cannabis-related drug products: Marinol (dronabinol) oral capsule, Syndros (dronabinol) oral solution, and Cesamet (nabilone) oral capsule. These products are THC products approved by the FDA for use in chemotherapy-induced nausea and vomiting. However, in 2018, the Farm Bill federally legalized hemp products containing no more than 0.3% THC. Though it was federally legalized, states were allowed to create their individual policies.
References
How CBD Works. Project CBD: How to Use CBD & Cannabis. https://www.projectcbd.org/science/how-cbd-works. Accessed July 2, 2020.
Crippa JA, Guimarães FS, Campos AC, Zuardi AW. Translational Investigation of the Therapeutic Potential of Cannabidiol (CBD): Toward a New Age. Frontiers in Immunology. 2018;9. doi:10.3389/fimmu.2018.02009
Bih CI, Chen T, Nunn AVW, Bazelot M, Dallas M, Whalley BJ. Molecular Targets of Cannabidiol in Neurological Disorders. Neurotherapeutics. 2015;12(4):699-730. doi:10.1007/s13311-015-0377-3
Russo E. Cannabinoids in the management of difficult to treat pain. Therapeutics and Clinical Risk Management. 2008;Volume 4:245-259. doi:10.2147/tcrm.s1928
Written by: Denise Cotter and Niyati Doshi
CBD otherwise known as cannabidiol is an active ingredient of cannabis and is naturally occurring from the cannabis plant. CBD is being tested all around the world for its therapeutic properties as a safe and non-addictive substance. CBD is a close relative of THC (tetrahydrocannabinol), which is known to cause the “high” usually associated with marijuana. Although both CBD and THC have been tested for its therapeutic properties, CBD does not cause the high/stoned/intoxicated state that THC does as it binds to different receptors in the brain. CBD can actually be used to neutralize the effects of THC, depending on how much of each compound is used.
CBD is being sought out as an alternative method of treatment in comparison to pharmaceutical agents with harsh side effects. This can be used as an aid in relief to chronic pain, anxiety, inflammation, depression, and other conditions. There are a wide range of diseases in which CBD is thought to be beneficial such as: autoimmune diseases (inflammation, rheumatoid arthritis), neurological conditions (Alzheimer’s, dementia, Parkinson’s, multiple sclerosis, epilepsy, Huntington’s chorea, stroke, traumatic brain injury), metabolic syndrome (diabetes, obesity), neuropsychiatric illness (autism, ADHD, PTSD, alcoholism), gut disorders (colitis, Chron’s), cardiovascular dysfunction (atherosclerosis, arrhythmia), and skin disease (acne, dermatitis, psoriasis). As mentioned in the PowerPoint provided, a new medication has recently come into the market for treatment of seizures known as Epidiolex, and the main component of this medication is cannabidiol oil.
Epidiolex is a prescription cannabidiol oil used in Lennox-Gastaut Syndrome and Dravet Syndrome. The product may be prescribed to those aged two or older, to patients who have either Lennox-Gastaut Syndrome or Dravet Syndrome seizure disorders, and have failed multiple seizure medications/therapies. Epidiolex is the only FDA approved product containing CBD for prescription purposes, in treatment of two rare seizures. As Epidiolex is the only FDA approved product on the market, there are various products on the market advertised as oils, topicals, capsules, vaping products, etc. to make CBD more readily available to the public for those who are unable to receive the prescription. Though there seem to be many benefits to CBD, many prescribers are not using Epidiolex off-label as it is very costly and not affordable, especially to those who don’t have access to health insurance. Those who purchase CBD oil or CBD based products for relief of chronic pain, anxiety, etc., should also be aware that since these products are unregulated by the FDA, the dose may be listed on the product, but it is not fully aware if one would be receiving that dose or something higher/lower. Essentially, the buyer is unaware of what they are receiving. CBD can be a helpful alternative without all the side effects of prescription medications and is becoming more prevalent on the market, but as there is limited data and studies being provided, the capacity of CBD is not fully aware, and should be discussed with a medical personnel before starting up the use of the product.
Reference(s):
“EPIDIOLEX® (Cannabidiol).” EPIDIOLEX.com, www.epidiolex.com/.
Peter Grinspoon, MD. “Cannabidiol (CBD) - What We Know and What We Don't.” Harvard Health Blog, 22 Apr. 2020, www.health.harvard.edu/blog/cannabidiol-cbd-what-we-know-and-what-we-dont-2018082414476.
“What Is CBD?” Definition of Cannabidiol & CBD Oil, www.projectcbd.org/cbd-101/what-is-cbd.
The topic of Cannabis seems very controversial whether it be for recreational or
medicinal purposes. CBD oil is making its way into headlines and being incorporated into a variety of products from lip balms, to skincare, to vitamins. The source is especially important because although people believe it is from the cannabis plant, the products marketed today are extracted from the plant hemp. The two sources of cannabis are from either sativa or indica. Cannabis indica has larger amounts of Cannabidiol or CBD and is known for relaxation, to reduce inflammation and to reduce intra-ocular pressure (for glaucoma). Cannabis sativa has larger amounts of Tetrahydrocannabinol or THC and is known to be more energizing, used for headaches, pain and nausea and stimulates appetite. CBD is known to not give the high that THC products have since it is not a psychotomimetic compound. Traditional medicinal marijuana can have many positive benefits, like reducing anxiety, relieving pain, and treating inflammation. It can also help with treatment of cough, cramps, insomnia, arthritis, gout, epilepsy, and even venereal disease. It is especially used to cure the nausea and vomiting associated with chemotherapy. Nonetheless, research about the effects of CBD oil for topical use is still underway. Many areas of dermatology from acne, to psoriasis, to inflammation, to pruritis, to skin cancer can be treated with cannabinoids. A type of endogenous cannabinoid AEA or arachidonoylethanolamide can induce lipid production in sebaceous glands at low levels but also induce apoptosis at higher levels. Since the leading cause of acne is overproduction of sebum, AEA can then decrease the appearance of acne. According to the Journal of Immunology, cannabinoids can also alleviate inflammation characteristics of allergic dermatitis. Because of CBD’s ability to heal inflammation and oil production, it can be the ideal combination for acne treatment. However, caution still needs to be taken when using products that are not FDA approved which may or may not be labeled correctly.
SBIRT Clinical Guidance Resources Marijuana web. Accessed May 21, 2020
Pertwee RG. Targeting the endocannabinoid system with cannabinoid receptor agonists: pharmacological strategies and therapeutic possibilities. Philos Trans R Soc Lond B Biol Sci. 2012;367(1607):3353-3363.
Cannabidiol (CBD) is a natural occurring compound in found in the cannabis plant. It is closely related to another compound known as THC. Both CBD and THC are classified as phytocannabinoids and share similar health benefits. However, THC produces the “high” associated with marijuana use while CBD is non-psychoactive and non-addictive.
CBD is not the same as marijuana; CMD is a single compound in the cannabis plant while marijuana is a type of cannabis plant that contains many naturally occurring compounds including CBD and THC.
The PowerPoint went over the mechanism behind CBD. While the exact mechanism of action is unclear, it is known to act on the cannabinoid (CB) receptors of the endocannabinoid system, which are present throughout the body. CBD is also a negative allosteric modulator of CB1 receptors, allowing it to inhibit psychomimetic effects.
While there are many CBD products available on the market, Epidiolex is the only one that is FDA-approved. It is indicated for two rare, severe forms of epilepsy: Lennox-Gastaut syndrome and Dravet syndrome. There are ongoing studies for test efficacy in treating other diseases including Parkinson’s, schizophrenia, anxiety, and arthritis.
Next, the PowerPoint discussed the safety of CBD. CBD is relatively well tolerated. Common side effects include decreased appetite, diarrhea, somnolence, fatigue, and rash. Patients on CBD should be monitored for drug interactions with other hepatotoxic drugs, sedatives, and herbs or supplements.
In conclusion, while CBD is becoming a popular, mainstream product with promising health benefits, there is still limited data on its safety and efficacy. Further studies are needed before CBD can be taken for any reason. Patients also need to be aware that some CBD products are being marketed with unproven medical claims and are not regulated by the FDA.
Reference:
What to Know About Products Containing Cannabis and CBD. U.S. Food and Drug Administration. https://www.fda.gov/consumers/consumer-updates/what-you-need-know-and-what-were-working-find-out-about-products-containing-cannabis-or-cannabis. Accessed May 21, 2020.
This powerpoint summarized the different CBD products and the medical uses of these products. Cannabidiol (CBD) is one of the active ingredients of cannabis more commonly known as marijuana. CBD is directly derived from the hemp plant. CBD is considered non-psychoactive and non addictive. How does CBD work? CBD has little binding affinity for either of the two cannabinoid receptors, CB1 and CB2. However, it acts on other receptors and ion channels to produce its medical therapeutic effects. It activates the serotonin receptor (5HT1A) when used in high doses, which helps produce an anti-anxiety effect. It also acts on the Villanoid receptors. It acts on the TRPV1 receptor, which functions as an ion channel and it is known to mediate pain perception, inflammation, and body temperature. Although there are many more receptors it interacts with, these are some of the ways CBD provides its functional effects. Epidiolex is a prescription CBD product which is indicated for Lennox-Gastaut Syndrome or Dravet Syndrome in patients 2 years of age and older. Other products include a massage candle to help moisturize skin, a spray, soothing serum to help with discomfort, CBD oil to help with anxiety, and many more. CBD products are being studied for parkinsons, schizophrenia, insomnia, arthritis, etc. Some side effects that patients can experience when using CBD products are decreased appetite, diarrhea, fatigue, rash, etc. Although this product has many benefits, there aren't any FDA regulations on them, which makes it harder for pharmacists to recommend these products to patients. The only product that is FDA approved is the Epidiolex. As a pharmacist, if a patient is using CBD products and they make you aware of it, it is very important to screen for drug-drug interactions with their prescription medications, especially the sedative medications or any over the counter or herbal supplements they might be taking to ensure they are using this safely. CBD products also can cause liver injury, which is something patients should be aware of if they have a past history of liver disease.
Reference:
How CBD Works. Project CBD: Medical Marijuana & Cannabinoid Science. https://www.projectcbd.org/science/how-cbd-works. Accessed May 21, 2020.