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6 Tips for Safe CBD Use

Americans are turning to this cannabis product for its possible health benefits, despite little guidance on how to use it

Four years ago, swimmer and six-time Olympic gold medalist Amy Van Dyken was in an ATV accident that left her paralyzed from the waist down and suffering from debilitating pain. After three and a half years of trying to treat the pain with prescription medications, Amy tried something new: cannabidiol, or CBD, a compound that comes from one of two forms of the cannabis plant, marijuana or hemp.

Van Dyken had originally purchased the CBD for her dog, who was being treated for cancer. But during an excruciating flare-up of her own pain, she decided to try CBD herself.

“It felt like a wave of warmth went over my body, and the nerve pain almost 100 percent subsided,” Van Dyken says.

Unlike tetrahydrocannabinol (aka THC, the chemical in marijuana responsible for the plant’s mind-altering effects), CBD does not get users high. But it’s gaining popularity as a pain reliever and for its other possible health benefits.

Now, Van Dyken, who told her doctor about the relief she has found with CBD—and who recently became a paid spokesperson for Kannaway, a cannabis company—says she doses herself with CBD every morning. And she has given up cortisone shots and other prescription treatments.

Van Dyken’s experience with CBD may be emblematic of a larger trend. In a recent Consumer Reports nationally representative survey of 1,003 adults, 13 percent of American adults said they had used CBD to treat a health issue; of those, nearly 90 percent said it helped. And a July 2018 study in the journal Cannabis and Cannabinoid Research found that most people who try CBD for health problems learn about it through friends, family, or the internet—not from their physician.

Despite the success stories, there’s surprisingly little scientific research about CBD’s efficacy, safety, and appropriate dosing, says Salomeh Keyhani, M.D., a professor at the University of California, San Francisco, who has published research on medical marijuana use. She says that while there is some research showing that cannabis products may help manage a few specific health conditions, for most benefits touted on the internet “there’s often little or no evidence.”

The paucity of evidence, however, is not necessarily due to the ineffectiveness of cannabis or CBD. Rather, government rules have made it difficult for scientists to use federal money to research the plant’s possible health benefits because it is classified as a schedule I controlled substance, just like ecstasy, heroin, or LSD.

Partly because official evidence is so hard to come by, people often treat themselves on the fly rather than seek guidance from a healthcare practitioner, experts say. Making matters more confusing, the products are not regulated by the Food and Drug Administration, which means that consumers can’t be certain that CBD products contain exactly what their labels claim.

Still, as more patients and healthcare professionals try CBD—and more states legalize its use—experts are beginning to develop strategies for how to use it more effectively and safely.

For example, in New Jersey—which recently expanded the categories of debilitating conditions eligible for the state’s medical marijuana programs—the state’s health commissioner, Shereef Elnahal, M.D., has started meeting regularly with medical students and physicians who want to better understand how to use CBD. He says he gets 200 to 300 visitors for each talk, many seeking information because their own patients are already trying CBD. “Neurologists have come back to me looking to hear how to treat neuropathic pain,” Elnahal says.

Below, some tips from patients and experts on using CBD safely.

What You Should Know

If you’re considering using CBD, be aware that there are many products on the market and that quality can vary. One way to choose wisely is to look for products from states that have legalized both the medical and recreational use of cannabis; they tend to have stricter standards. (See our map, below, for the legal status of cannabis products across the country.) Also, read more about shopping for CBD products, including the pros and cons of purchasing online; and look into the different forms of CBD—such as pills, rubs, drops, and vape pens. Finally, consider the advice below.

1. Don’t expect miracles. Preliminary research suggests that CBD could offer some health benefits, especially in treating epilepsy. In fact, the FDA recently approved a CBD drug—Epidiolex—for two rare but devastating forms of that condition. Other research hints that CBD may also help with other health problems, including multiple sclerosis, pain, and anxiety.

But most of what doctors know about CBD is anecdotal, according to Donald Abrams, M.D., an oncologist at Zuckerberg San Francisco General Hospital who has been researching cannabis for more than 20 years. And for most health problems, CBD’s benefits are more conjecture than proof.

That doesn’t mean you can’t try CBD for other purposes. But you should recognize that its potential benefits are largely unproven. “I’ve heard from patients that CBD can be effective for all kinds of things,” Abrams says, “but the data in the medical literature in regards to what CBD does is limited to a handful of randomized controlled trials, prior to the Epidiolex studies.” So while you may hear of people using CBD to treat everything from anxiety and back pain to attention deficit hyperactivity disorder and insomnia, don’t expect a cure-all.

2. Consult with your doctor. Your healthcare provider should be kept informed of all the drugs and supplements you take, including CBD, in order to best manage your overall care, help you determine the best treatment options for your condition, and guard against potential drug interactions and other risks (see below). “Patients are generally reluctant to tell their oncologists about complementary therapies in general for fear of being castigated,” Abrams says. But if you’ve started using CBD, it’s in your best interest to let your doctor know.

In some states, in fact, to obtain CBD, you’ll need a recommendation from a doctor. (Physicians technically can’t “prescribe” CBD or other products that are illegal at the federal level, but most states allow physicians to “recommend” CBD.) And while your primary healthcare provider may not be familiar with CBD, she might be able to refer you to a healthcare provider who is.

3. Watch for harmful drug interactions. Research suggests that CBD can undermine the effectiveness of some drugs and increase the risks of others, especially at high doses. “Highly concentrated CBD tinctures may interfere with the liver enzyme system that metabolizes a lot of pharmaceuticals,” Abrams says. That includes blood thinners such as warfarin (Coumadin and generic), antidepressants such as fluoxetine (Prozac and generic), and cholesterol-lowering statins such as atorvastatin (Lipitor and generic).

Also, cannabis plants contain other compounds (often referred to as cannabinoids) that could be in your CBD product. The most notable one, of course, is THC, which can alter your cognition and have long-term effects on learning and memory loss, according to the American Academy of Neurology. So look for a product that says it contains only CBD rather than “cannabinoids,” which could indicate the presence of other compounds, such as THC. CBD-only products should contain no THC, or minuscule amounts.

4. Use CBD to supplement conventional care, not necessarily replace it. Experts don’t recommend that you use CBD instead of your prescription medications to treat serious conditions such as cancer, multiple sclerosis, or Parkinson’s; rather, CBD could serve as an adjunct therapy when used cautiously and with your doctor’s knowledge. “The majority of the time patients are not able to, or are not recommended to, switch from their prescription medications to just CBD,” says Ranga Krishna, M.D., chief of the neurology-stroke service at New York Community Hospital in Brooklyn and founder of CBD Databank, an online platform that collects and shares data on the medical use of cannabis. The risks of replacing any proven conventional treatment with an alternative unproven therapy, such as CBD, have not been well-studied.

But there are some health problems, such as pain or anxiety, where CBD may be helpful in place of certain pharmaceuticals, according to experts. So if you and your doctor decide you can substitute CBD for a prescription drug, you need to do that carefully—and under the supervision of your doctor—to guard against withdrawal symptoms and to ensure that your health condition continues to be well-managed, Krishna says.

5. Be extra cautious if you’re pregnant or nursing. While CBD seems to pose little risk of addiction and is associated with relatively mild side effects, there is sparse research on the safety of CBD in women who are pregnant or breastfeeding. And recent research in the August 2018 issue of Pediatrics found that cannabinoids can be passed from a pregnant woman to her fetus. Experts are particularly cautious when it comes to marijuana use, not just CBD, among pregnant and nursing women—a practice that is on the rise, according to data from the National Survey on Drug Use and Health.

“There’s still a lot we don’t know about how marijuana affects a baby’s rapidly developing brain,” Mary E. O’Connor, M.D., a co-author of the Pediatrics report, said in a statement from the American Academy of Pediatrics. And the Centers for Disease Control and Prevention says that cannabis can be harmful to a baby’s health and increase the risk of developmental problems. “Based on what we know now, we’re advising women who are pregnant or nursing that the safest choice for their child is to avoid marijuana,” O’Connor said.

6. Look for a dispensary. Because there are so many different types of CBD products and no federal regulatory standards, healthcare providers typically don’t know which forms or dosages of CBD might work best for various conditions. But experts offer some rough guidelines. For instance, Mitch Earleywine, Ph.D., a professor of psychology at the University at Albany, State University of New York, recommends that when using a CBD tincture, start with a small dose, like 10 mg, though he says you may not feel an effect until you reach 30 mg per day for at least a week.

While some doctors may feel comfortable pointing to a specific dose, many will direct patients to speak with staff members on the front lines at a dispensary, Abrams says. That’s a state-licensed facility where medical marijuana patients can purchase cannabis products in states that have legalized it.

Though training requirements vary from state to state—and from facility to facility—dispensary employees tend to have the most expertise about mode of delivery and dosage, says James Yagielo, CEO and co-founder of HempStaff, a company that specializes in cannabis recruiting and training for dispensary jobs. Yagielo explains that most dispensary staffers have undergone some type of cannabis education, or have been working with the products for years. Still, you may want to ask about their background and experience.

You might even find a dispensary with a pharmacy technician or nurse who can advise you. “Some states have gone way more medical with their dispensaries, and they look like a doctor’s office and have a medical professional on staff, as opposed to states that legalized years ago, when the dispensaries looked like an old fashioned head shop with Bob Marley posters on the wall,” Yagielo says.

Wherever you go, a good rule of thumb when starting out with CBD, Abrams says: Begin with low doses, and increase the amounts slowly.

Americans are turning to CBD despite limited research. Consumer Reports shares details about safe CBD use.

What drugs should not be taken with CBD?

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Contents

  1. CBD interaction with drugs & medication
  2. Drugs that should not be taken with CBD
  3. Does CBD oil affect blood pressure?
  4. Does CBD oil thin the blood?
  5. Does caffeine counteract CBD?

Cannabis is a complex plant, with hundreds of chemicals and over 100 distinct cannabinoids. The little research that examines cannabidiol or CBD, the second most common cannabinoid found in cannabis, shows evidence of potential health benefits for a wide range of conditions. As CBD becomes more mainstream, however, a key question comes to mind, “How will CBD interact with my current medication?”

Currently, sparse research suggests that CBD can illicit problematic interactions with certain other prescription drugs. The findings are far from conclusive — further research is still needed on CBD’s interaction with different medications. Many doctors and researchers urge individuals using CBD medically or recreationally to be cautious about mixing it with other prescriptions and to consult healthcare providers about possible interactions.

Many doctors urge individuals using CBD to be cautious about mixing it with other prescriptions and to consult healthcare providers about possible interactions.

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CBD interaction with drugs & medication

Have you heard of the grapefruit test? Many prescription drugs will include grapefruit warnings on the label, advising against consuming the citrus fruit while taking medication. Many medications are broken down in the liver and small intestine by a group of proteins called cytochrome P450 enzymes (CYPs). This process is what delivers a medication’s benefits to the intended target.

Grapefruit disrupts the activity of CYPs and slows the way these proteins usually break down medication. The fruit also increases the side effects and duration the drug stays in the system. One 2013 study titled “Grapefruit Medication Interactions: Forbidden Fruit or Avoidable Consequences?” published in the Canadian Medical Association Journal showed that grapefruit can increase blood content levels when interacting with at least 85 different drugs. The reported consequences were severe, including irregular heartbeat, organ failure, internal bleeding, and death.

Further, a 1993 study conducted by pharmacology researchers at the University of California, San Francisco, and published in the journal Biochemical Pharmacology, discovered that CBD, much like grapefruit, disrupts the normal function of cytochrome P450 enzymes in mice. The study postulated that while the blockage could allow patients to take lower doses of their prescriptions, it could also cause a toxic buildup of chemicals in the body. Since this study’s publication, several scientific and medical journals have published evidence of the grapefruit-like effects of CBD in humans.

The type, quality, and purity of CBD administered all affect how it interacts with your body and medication. The timing of when you take CBD and any other prescription drug also factors into how the two may interact in your body. And of course, every individual responds to medications differently, depending on genetics, age, weight, and other factors.

medical CBD

The type, quality, and purity of CBD administered all affect how it interacts with your body and medication. Photo by: Gina Coleman/Weedmaps

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medical CBD

Let’s examine the current research on CBD’s interaction with several common prescription and over-the-counter medications.

Should I take CBD with ibuprofen?

Ibuprofen is a nonsteroidal anti-inflammatory (NSAID) medicine that reduces pain and inflammation in the body. Ibuprofen has a risk of blood-thinning and can cause dizziness, shortness of breath, and nausea.

Potentially, CBD can increase the duration and strength of ibuprofen, thereby increasing the risk of adverse side effects. No human studies to date examine CBD’s interaction with NSAIDs specifically. Still, two studies conducted on animal models in 2006 and 2008 and published respectively in the journals, Pain and Pharmacology, suggest that other cannabinoids may work synergistically with NSAIDs like ibuprofen to reduce pain.

Patients should consult with their healthcare provider before taking ibuprofen with CBD.

Should I take CBD with warfarin?

Warfarin, also known under the brand name Coumadin, is an anticoagulant (blood thinner) medication used to prevent the formation of harmful blood clots that could potentially cause heart attacks or strokes. Warfarin’s risks include severe bleeding, headaches, swelling, or sudden pain in extremities.

In 2017, researchers at the University of Alabama, Birmingham, conducted a study published in Epilepsy & Behavior Case Reports which showed that CBD increases the effects of drugs used for blood-thinning by slowing down how the body metabolizes warfarin and prolonging its presence in the system. By increasing the duration of warfarin’s presence in the body, CBD could potentially exacerbate some of the associated risks.

Patients taking generic warfarin or Coumadin should consult their healthcare provider for individualized information and get blood tests before beginning a CBD regimen.

Should I take CBD with thyroid medication?

Thyroid medication is used to treat thyroid disorders, most commonly hypothyroidism (an underactive thyroid) via thyroid hormone replacement, and hyperthyroidism (an overactive thyroid) via anti-thyroid medication. Different medications achieve these objectives through different pathways in the body. Side effects of thyroid hormone replacement therapies include chest pain, anxiety, headaches, and vomiting. While rare, anti-thyroid medication side effects can include rash, itching, fever, aches, and headaches.

Little research studying interactions between CBD and common thyroid hormone replacement and anti-thyroid medications currently exists. Patients taking thyroid medication who want to try CBD should consult with their physician.

Should I take CBD with Eliquis?

Eliquis (generically called apixaban) is a blood thinner used to lower the risk of stroke or a blood clot in veins, the heart, the lungs, and the legs following knee or hip replacement surgery. Eliquis increases the risk of severe bleeding, and patients taking Eliquis are typically prescribed precise dosages by their doctor.

CYP proteins process Eliquis in the liver, the same proteins on which CBD acts to delay metabolization. This process could cause an overdose of Eliquis’ chemicals in the body and a high risk of severe bleeding.

Patients taking Eliquis should speak to their doctor before using CBD products.

Should I take CBD with Plavix?

Plavix is the brand name of the drug clopidogrel, frequently prescribed for patients who have had or are likely to have a heart attack. The drug works by blocking blood platelets from forming clots in arteries near the heart.

According to a 2011 study published in the journal Life Sciences, it is possible that CBD has an inhibitory effect on CYP2C19, the enzyme that metabolizes Plavix. This could cause Plavix to remain longer in the body and weaken its overall effects. Further research is required to determine whether this could lower Plavix’s effectiveness in preventing heart attacks.

Patients using Plavix or clopidogrel should consult their physicians as to whether they should use CBD.

Should I take CBD with Tylenol?

Acetaminophen, the generic name for Tylenol, is a common drug used for pain and fever relief. Acetaminophen carries a risk of liver damage and disease, with side effects including nausea, headaches, and insomnia.

Acetaminophen and CBD both are metabolized by CYP450, which lowers the effectiveness of both chemicals as they’re processed in the body. One controversial 2019 study, conducted by the University of Arkansas on mice and published in the journal Molecules, claimed that high doses of CBD contributed to liver toxicity, which could compound acetaminophen’s liver damage potential. However, the study’s authors have been accused of cherry-picking research and designing experiments to showcase potential CBD toxicity. The one study they cited with human test subjects did not show liver toxicity from CBD.

More research is required to confirm potential interactions between CBD and acetaminophen. Patients looking to take both simultaneously should consult their physician.

Should I take CBD with metoprolol?

Metoprolol is a beta-blocker designed to treat high blood pressure by reducing the heart rate and changing the release of epinephrine, a hormone involved in stress and other processes. Beta-blockers lower blood pressure and sometimes produce side effects such as dizziness, nausea, stomach pain, heartburn, and cold hands and feet.

No studies have examined potential interactions between CBD and metoprolol. However, some placebo-controlled research conducted on healthy people at the University of Nottingham in England and published in 2017 in the journal JCI Insight has linked CBD with decreased blood pressure when taken on its own. For patients taking metoprolol, however, the combination with CBD could potentially have negative impacts on blood pressure.

A 2011 study performed on mice and published in the British Journal of Pharmacology also shows that CBD has potential nausea-reducing properties, which may help soothe side effects associated with metoprolol.

Patients taking metoprolol or other beta-blockers should consult their doctor as to whether to consume CBD.

Should I take CBD with metformin?

Metformin is a medication prescribed to adults with type 2 diabetes to help control blood sugar levels. Side effects of metformin include low blood sugar, nausea, diarrhea, vomiting, and muscle pain.

One 2006 study published in the journal Autoimmunity showed that CBD reduced the incidence of diabetes in animal models. To date, however, very little research has specifically covered CBD’s potential in human diabetes treatment or interactions with metformin. Only one study, conducted by the American Diabetes Association and published in 2016 in the journal Diabetes Care, has examined the efficacy of CBD in patients with type 2 diabetes and found it had no significant impact on glucose levels.

More research is needed on CBD’s interaction with diabetes. Patients taking metformin should talk to their doctor about whether CBD is right for them.

Should I take CBD with Xanax?

Xanax (generic name alprazolam) is a benzodiazepine medication used to treat panic disorders, anxiety, and depression. Common side effects of Xanax include drowsiness, lack of coordination, memory loss, and early-morning anxiety.

Xanax breaks down in the liver via an enzyme called CYP3A4, which is inhibited by CBD. Taking CBD could potentially increase the amount of time Xanax is in the system and prolong or increase the likelihood of unwanted side effects. CBD may one day be considered an alternative to Xanax as various research, including a 2011 study published in the journal Neuropsychopharmacology, has documented the cannabinoid’s potential anti-anxiety properties.

No research has explicitly documented interactions between Xanax and CBD. Patients taking Xanax who are interested in CBD should speak to their healthcare providers for more information.

Should I take CBD with statins?

Statins are a classification of drugs designed to lower cholesterol and protect against heart attack and stroke. Common side effects of statins are muscle soreness, blood sugar increase, headaches, and nausea.

Statins are processed by CYP function in the liver, which CBD inhibits. While no research has specifically studied interactions between statins and CBD, the cannabinoid could potentially increase the strength and duration of statins in the system and the risk of unwanted side effects.

Patients taking statins should speak to their healthcare provider before using CBD.

Drugs that should not be taken with CBD

CBD’s documented effects on liver function and enzymes that metabolize several medications are relevant when considering whether or not to consume CBD with certain drugs. CBD acts on the same metabolites as grapefruit — therefore, many of the prescription drugs that carry grapefruit warning labels may have similar risks when taken with CBD.

CBD acts on the same metabolites as grapefruit — therefore, many of the prescription drugs that carry grapefruit warning labels may have similar risks when taken with CBD. Photo by: Gina Coleman/Weedmaps

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These drug classifications include a large percentage of existing prescriptions, such as benzodiazepines, antihistamines, haloperidol, antiretrovirals, statins, cyclosporine, sildenafil, warfarin, and other drugs metabolized by CYP3A4 and CYP2D6.

Clobazam, used to treat epileptic seizures, is another type of drug that may not be advisable to take in conjunction with CBD. However, Epidiolex is an FDA-approved, CBD-based drug that physicians may prescribe to treat epilepsy. A significant amount of data, derived from clinical trials, exists on Epidiolex, although the drug can also cause adverse effects, according to a 2019 study conducted by researchers at Columbia University and published in the journal F1000Research.

No research conclusively warns patients against taking these drugs with CBD, though the previously cited 2013 study published in the Canadian Medical Association Journal has shown that grapefruit and drug interactions can lead to severe effects, including irregular heartbeat and sudden death, kidney failure, and muscle damage. Every patient’s case is unique, and individuals should speak to their healthcare providers if they are considering taking CBD in combination with particular prescription medications.

Does CBD oil affect blood pressure?

A previously cited 2017 study titled, “A single dose of cannabidiol reduces blood pressure in healthy volunteers in a randomized crossover study” published in the journal JCI Insight, supports CBD’s ability to lower blood pressure. Researchers also suggest that the anxiety- and stress-reducing properties of CBD may contribute to the overall ability to lower blood pressure. However, CBD taken with blood pressure medication or beta-blockers could potentially cause both drugs to double up on each other and lower blood pressure to unhealthy levels.

Does CBD oil thin the blood?

No research shows that CBD oil taken on its own can thin the blood. CBD oil does increase the effects of blood-thinning medications, such as warfarin, and could potentially push the presence of warfarin beyond therapeutic levels, as the previously cited 2017 study published in Epilepsy & Behavior Case Reports showed.

Does caffeine counteract CBD?

Caffeine and CBD are two substances gaining in popularity, particularly when they’re mixed. Caffeine can keep sleep-deprived individuals alert and clear-headed. Further, a 2007 study on rats published in the journal Pharmacology Reports showed that caffeine is metabolized by CYP enzymes, which CBD inhibits. This could extend the time caffeine stays in the body and has the potential to extend the stimulating effects of caffeine.

The information in this article is based on current research and should not be construed as medical advice. Please speak to your doctor or healthcare provider if you have questions regarding your medication and CBD use.

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