Whenever registered nurse Heather Manus is out and about in public, she can't seem to escape discussions of cannabidiol (CBD), a suddenly ubiquitous compound found in cannabis.
Manus often hears people discussing CBD over lunch, or that someone has started giving CBD products to her dog; another to help with human arthritis. A lot of senior citizens take it regularly, she said, to help with the many aches and pains of a long life. Yet many of these conversations reveal a lack of solid information about CBD and its uses.
The 2018 Farm Bill reshaped the legal landscape, opening doors to hemp-derived CBD products nationally. However, the situation remains wildly complicated, with wide variations in state cannabis laws and little oversight of a CBD market that's projected to reach $20 billion by 2024, according to BDS Analytics.
As with much about the effects and effectiveness of cannabis, little is scientifically proven about the medical applications of CBD, but there are promising indications that it may help with pain, inflammation, anxiety, and overall health. Even the federal government has signaled its interest: The Food and Drug Administration issued its first-ever cannabis-derived drug approval for Epidiolex, which treats certain severe forms of epilepsy.
CBD is not intoxicating, but it is psychoactive in that it may relieve feelings of anxiety, stress, or pain. Though most patients can use CBD in a variety of forms without an issue, medical professionals wonder whether that is really the best approach. And when few medical professionals have been trained in cannabis medicine, where can consumers turn for the best information? Increasingly, the medical professionals who dealt most directly with patients are working to be educated.
Manus is the founder of Cannabis Nurses Network, through which she said aims to inform nurses about the use, benefits, and potential risks of cannabis and cannabis-derived medicines. Nurses can be the first source of information about cannabis because they typically spend more time with patients, have a direct line of communication to doctors, and can serve as patient advocates — even taking the initiative to ask a doctor to recommend an appropriate cannabis regimen. Courts have found that doctors have a constitutional right to recommend, though not prescribe, marijuana, but some doctors still fear the potential risk to their license.
“The nurses have been really leading the way,” Manus said. Now other organizations are aiming to close the knowledge gap.
“Our belief is that nurses as front-line medical practitioners need to know about cannabinoids and their effects on patients so that they can offer the best treatment,” said Malcolm Youngren, Chief Operating Officer of the Pacific College of Oriental Medicine and the director of the school's New York campus in Manhattan.
The school recently began offering a medical cannabis certificate for health-care professionals. Some 55 million Americans used some kind of cannabis product in 2018, he said, while about 70% of current health-care professionals say they are not well-trained to know how to advise their patients about cannabis.
Though the U.S. Food and Drug Administration (FDA) says it's working on rules governing the sale and use of CBD, so far consumers and producers have little guidance. Many states tolerate CBD sales, even where marijuana remains prohibited, but the FDA has issued warning letters to CBD-producing companies it believes have made unproven claims for their products.
A study released by Penn Medicine in November of 2017, published in the Journal of the American Medical Association, found that a staggering 70% of CBD products sold online are mislabeled, containing either more CBD than claimed or less. That means only three-tenths of the products contained CBD within 10% of the amount claimed on the label.
With so many variables, where should consumers start with CBD?
“We always recommend people start low and go slow. Begin with a very small amount and then work your way up to an effective dose,” Manus said. Quality matters, she added.
“We encourage our patients not to buy CBD in a gas station,” she said. Where there is a state-legal cannabis program, she said, the best bet is to go through the legal market and buy through a licensed dispensary. Where that is not available, there are often CBD specialty stores, where staff can usually offer advice on doses and effectiveness, and usually have information on the source of the CBD.
Jenna Champagne, another nurse member of the Cannabis Nurses' Network, encouraged patients to talk with their health professional before taking CBD. In some cases, the cannabinoid may interact with other medicines, either blunting or accelerating their combined effectiveness.
Champagne had five suggestions for someone considering CBD:
1. Learn first
Talk to a health-care professional, Champagne said, or at least educate yourself before beginning a regimen of CBD, or any other herbal supplement. Champagne advocates for CBD as an important way to keep bodies — and the endocannabinoid system — in balance. But like more than 100 other cannabinoids found in the cannabis plant, CBD has the potential to interact with other substances.
“Make sure you don't have any considerations that warrant medical oversight,” she said. “CBD combined with the wrong medication could become a risk factor,” she noted, particularly with blood thinners.
2. Not all products are created equal
Look for medical-quality suppliers that have been tested by a third party for purity and the concentration of CBD. There are also numerous methods for extracting CBD from the plant. Champagne recommends looking for broad-spectrum products that maintain as much of the complex chemicals of the plant as possible.
“Don't just buy it because it has fancy marketing,” Champagne said.
3. Do your research
In addition to speaking with a medical professional about potential benefits and side effects, each of the experts interviewed suggested care in the source of CBD. Champagne uses the mnemonic acronym F.L.O.W., which stands for Flower-derived, Lab-tested, Organic and from the Whole plant, saying products that concentrate the cannabis plant with all of its complexity intact are superior for health in the long run.
Youngren cited studies that found contaminants including heavy metals and pesticides in commercially available CBD products. Without FDA evaluation, consumers have little protection, while there remains a patchwork of laws governing the sale of CBD products around the country, and a variety of extraction methods in use.
“It's a massive issue,” Youngren said.
4. Use the whole plant
With the passage of the 2018 Farm Bill, much of the CBD on the market throughout the United States has been derived from hemp. It's genetically the same plant as marijuana, but under the federal definition, it must have less than 0.3% THC.
That's OK, said Manus, CBD is CBD is CBD. But studies have pointed to the entourage effect, which shows that cannabinoids seem to work better together. Champagne suggested buying CBD products derived from the whole flower. Industrial hemp has great uses, she said. It replenishes the soil and makes great clothing but has few flowers.
“That's where all the magic happens,” Champagne said.
5. Know your goal
Some may want a sleep aid, others pain relief or improved health. While Youngren is not a medical practitioner, he suggested looking at complete health goals, any medications taken regularly, as well as diet and exercise.
“If people are using CBD, I think they should know what they want to get out of it,” Youngren said.
The Pacific College of Oriental Medicine also teaches acupuncture and massage therapy, with a focus on maintaining the body's balance, or homeostasis. Youngren said students are taught to see health as more than an absence of sickness or pain, but as a positive approach to a balanced life. He extended that to CBD use.
“It shouldn't just be that there's a CBD cookie in front of me, I think I'll eat that. It should be taken more methodically,” he said. That should include keeping notes on when CBD is ingested and how much, helping move toward the correct amount while you're starting low and going slow.
Feature image: Cannabidiol (CBD) is becoming a part of many people's health and wellness regimen. It's important to discuss CBD use with a health professional to examine possible interactions with other medications or effects it may have on the body. (Gina Coleman/Weedmaps News)