With the massive expansion of interest in CBD products, clinicians need to know how to address their patients' questions.
Lifelong Learning in Clinical Excellence | February 4, 2020 | 4 min read
By Ryan Vandrey, PhD, Johns Hopkins Medicine
The CBD/hemp marketplace is immense and we can’t pretend it doesn’t exist or that people won’t try these products. Thus, the best path forward right now is for clinicians to be part of the conversation, to educate themselves and their patients, and to contribute to data collection efforts that further the knowledge base available. In the absence of good clinical trials data, clinical decision-making needs to be made based on the risk-benefit to the individual and availability of alternative treatment options. Evaluate it as you would any other novel, unapproved therapeutic agent.
Here are some key points for clinicians to know when asked about CBD/hemp products:
1) Don’t be afraid to talk to your patients about CBD, hemp, or medicinal use of cannabis.
There’s a lot of misinformation out there, so being open to having the conversation is important. Educate yourself about the types of cannabis/hemp products out there, why they are being used, and where true therapeutic potential exists. Once you’re willing to engage in the conversation, the first question to ask your patient is why they are interested in CBD and what they think it will do for them. From there, determine whether or not there is evidence to support that use.
2) Be mindful of potential drug-drug interactions with CBD/hemp products.
There’s increasing evidence that CBD may be a potent inhibitor of several CYP450 enzymes. Thus, please be mindful of potential drug-drug interactions with CBD/hemp products and other medications metabolized by CYP1A2, CYP2C19, CYP2C9, CYP2D6, or CYP3A.
3) Know that many CBD/hemp products also contain low concentrations of THC (the main psychoactive constituent of cannabis).
These small doses of THC may contribute to the therapeutic effects observed in individuals who use CBD/hemp products, but it also might cause positive drug tests or impact functioning. This will depend on the amount of THC in the product and the amount and frequency in which it is used. Anyone who is subject to workplace drug testing should be mindful of this.
4) Quality control is an issue for this industry.
Several studies have shown that many CBD/hemp products are not accurately labeled with respect to dose, and many contain contaminants ranging from pesticides, residual solvents, or other psychoactive/dangerous drugs not labeled on the product. The FDA has issued warning letters to several manufacturers for selling “CBD” products that contain no CBD and for making illegal claims about therapeutic benefits.
If a decision is made that a patient should try using CBD, a clinician should recommend that the patient perform due diligence in finding a reputable product to use. This kind of information can be obtained from non-profit organizations, internet forums, and patient advocacy groups that specialize in the therapeutic use of cannabis.
5) Ultimately, the decision to try CBD/hemp products needs to be made by the patient and provider together, weighing the risks and benefits of CBD/hemp versus alternative available treatment options on a case-by-case basis.
If the decision is made to try it, the clinician should follow up with the patient to assess the clinical impact. CBD by itself appears to be a very safe molecule and does indeed have demonstrated therapeutic benefit for rare types of epilepsy, and there is promising evidence for other health conditions.
That being said, there is risk of harm given the potential for getting a contaminated product, or interactions with other medications. In addition, there is insufficient data to inform selection of the best product/dose for any health condition other than epilepsy so there will be a trial and error period of dose titration required, which may not lead to positive clinical outcomes.
I would not recommend that individuals use CBD/hemp for general wellness (in the absence of clinical health need) as there is no data to indicate that this promotes improved health, and the aforementioned risks remain.
6) Know that hemp, and CBD derived from hemp, is now federally legal from a drug control standpoint (i.e. it is no longer controlled by the DEA).
The FDA is still determining regulations for the now legal hemp/CBD industry. The legalization of hemp has led to an enormous expansion of the industry, and this expansion is likely to continue in the foreseeable future. Hemp and CBD is now available in hundreds, if not thousands, of retail products, and is pervasive in the community.
7) The last thing is that we need increased dissemination of clinical outcomes, both positive and negative, from individuals using these products.
I encourage clinicians to write case reports, case series, discuss with their colleagues, and encourage patients to participate in research registries. I’m involved with a patient registry study with the Realm of Caring Foundation, a non-profit in Colorado, where we collect information from patients using cannabis for medicinal purposes . This data is collated across thousands of individuals to help identify trends in health impacts for people who use cannabis products for a variety of health conditions. In the absence of large clinical trials, this type of data is needed to better guide clinical decision making in the future.