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 CBD And Grapefruit Have In Common When It Comes To Drug Interactions: Risks You Should Know
Interest in cannabidiol (CBD) is exploding. Now that major retailers are carrying CBD products, plus an enormous selection online, curiosity is only going up. But we also need some healthy skepticism and caution to balance out the exuberance. CBD research is still in the early stages, and marketing is predictably outpacing facts. Concerns about safety, among other topics, are getting lost in the hype.
Apart from a short list of possible side-effects, bigger concerns revolve around how CBD interacts with other drugs. Here’s a brief breakdown of possible risks if you’re thinking of trying it out.
What CBD and grapefruit have in common
You’re probably familiar with “grapefruit warnings” that appear on a variety of medications, or maybe your doctor or pharmacist has told you to avoid grapefruit or grapefruit juice when taking a particular med.
The reason for the warning is that grapefruit contains compounds called furanocoumarins that bind with and effectively neutralize enzymes in the gut (specifically a type called CYP450 enzymes), which help break down and eliminate drugs from the body. When these enzymes can’t do their job, too much of the drug enters the liver and flows unprocessed into the bloodstream. That elevates risk of having dangerously high levels of the drug in your system.
CBD is similar to grapefruit in that it also binds with those enzymes, but research suggests that it’s possibly even more potent because it binds in multiple parts of the gut and liver (grapefruit mainly affects enzymes within the small intestine). Once an enzyme has been inhibited, the effect isn’t immediately reversed. It can take days for enzyme function to return to baseline and start the process again.
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In particular, research has found that CBD is a “potent inhibitor” of two enzymes (CYP3A4 and CYP2D6) that affect many common drugs, including antihistamines, benzodiazepines, certain antidepressants and statins.
What’s the risk?
The enzymes that both grapefruit and CBD inhibit are thought to break down a significant percentage of prescription and over-the-counter medications, so the potential for problems could be high.
A low dose of a med could become a high dose if it’s not properly broken down and eliminated. A high dose of a med could become a dangerously high dose, or even an overdose. Drugs with a narrow “therapeutic window” (they must stay within a certain blood-concentration range) are especially susceptible.
One of the big problems with CBD at the moment is we don’t really know yet which drugs are affected the most, and it’s difficult to identify exact levels of risk because the research has a lot of catching up to do after decades of science-blocking illegality. But since the compound appears to exert similar effects as grapefruit, caution is needed.
What’s the best path forward?
At a minimum, the evidence at this point suggests that grapefruit warnings on medications should also apply to CBD. And it’s important to check with your doctor before taking CBD, especially if you’re taking other medications.
The market for CBD products is predicted to pass $22 billion over the next four years, and that’s coming with the expected hurricane of fact-obscuring hype. With so much fanfare, it’s easy to ignore the fact that CBD is a potent compound that’s far from exhaustively understood. Research is uncovering upsides of taking it for a variety of conditions, and we’ll likely see more to come, but it’s also on us to recognize that this is an unfolding story and proceed with caution.
We’re still in the early stages of CBD research and marketing is predictably outpacing the facts. Here’s a brief breakdown of drug-interaction risks you should know.