CBD Update: New Research and Legislation

Cannabidiol, also known as CBD, is an active chemical found in cannabis. Unlike THC, CBD does not have psychoactive properties. While both THC and CBD derive from marijuana, CBD can also be sourced from hemp plants. There is a great deal of interest in CBD for chronic pain as well as other medical conditions including anxiety, epilepsy, post-traumatic stress disorder, substance use disorders, etc.

The legality of  CBD is a sticky wicket. In 2018, the US Food and Drug Administration approved Epidiolex® to treat pediatric seizures in children with Lennox-Gastaut and Dravet syndrome. At this point, this is the only FDA-approved CBD drug, although an oral/nasal spray called Sativex, currently approved in Europe and Canada for severe resistant multiple sclerosis spasticity, is undergoing Phase III clinical trials in the United States. Although marijuana is still listed as a Schedule I substance by the FDA, the 2018 Farm Bill made hemp legal in the US (Grinspoon, 2021), adding another level of complexity to the legal status of CBD.

There continues to be a high level of interest in CBD for mitigation of chronic pain, including non-specific low back pain. While there is good anecdotal evidence for its efficacy, there are some significant barriers to FDA approval. One is lack of consistent results from clinical trials, proving that CBD products (topical or oral) are superior to placebo (Sholler, Schoene et al., 2020). The second challenge, which is perhaps more significant is lack of consistency between various preparations, and lack of oversight in the manufacture of many CBD products.

This is not to say that all CBD products lack quality control. A case study involving two back pain patients, one from a lumbar compression fracture and the second following surgical resection of a spinal tumor, showed evidence of significant pain reduction using a CBD cream sold under the brand: Baskin Essentials Body Wellness Cream (Eskander, Spall et al., 2020). According to study authors, this product was third-party tested to ensure active ingredients were as stated on the label.

Also, individuals who intend to use CBD long-term should keep in mind that it is not a benign substance. Side effects include nausea, fatigue and irritability (Grinspoon, 2021). In addition, CBD can interact with blood thinners such as warfarin which may create a bleeding risk.

How does CBD work? Cannabidiol functions within the body’s endocannabinoid signaling systems in the central nervous system (CNS), to change the way neurotransmitters communicate. CBD reduces the activity of nociceptive neurons which transmit pain signals to the brain. In addition, CBD can activate what is known as the “descending inhibitory” pain pathway that blocks pain signals via a neurotransmitter called GABA. There is also some evidence that CBD enhances the effect of serotonin, a neurotransmitter that plays multiple roles in mood, sleep, wound healing and reward.

Because CBD is not federally regulated, individuals who want to use it should be careful about the source. Experts specializing in CBD products recommend looking for a cannabinoid analysis which reveals that weight and concentration of cannabinoids in the product, a heavy metals analysis and a pesticides analysis (Silva, 2022). Also look for third-party testing. Finally, a certificate of analysis (COA) on the product is a useful measure for quality assurance.



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