It’s out, the Medicinal Cannabis Clinicians Society has come out with guidelines stipulating what clinicians need to know about CBD. This could not have come at a better time as the global conversation on CBD has now caught fire. Controversies and hearsay have dominated the talks and it was high time that the pertinent questions on CBD got addressed. Especially where stakeholders (clinicians) are involved, it’s critical to be on the same page. Below is a rundown of what the society construes to be true of CBD and its therapeutic potential in other words titled “clinicians guide to CBD.”
The Medical Cannabis Clinicians Society is made up of a network of clinicians in and out of the UK who are involved in medicinal cannabis research and treatment. The association provides a platform for discussion and consultations on this subject.
What is CBD?
CBD, or cannabidiol, is one of the 113 phytocannabinoids that are found in cannabis. It is also a lipophilic molecule that is produced in the trichrome glands of the female cannabis plant. CBD is a molecule that is non-psychotropic and non- psychomimetic. It is also of great interest to the medical community because of the “multi-modal properties is has shown in the management of different medical conditions.”
Most of the CBD in the market is extracted from hemp cultivars that have less than 0.2% THC.
What is the Endocannabinoid System (ECS)?
The ECS is a cellular signaling system that is present in all vertebrates. It is made up of endogenous cannabinoids, CB1 & CB2 receptors, and metabolic enzymes. This system is involved in the regulation of the following functions:
- Autonomic functions
- Bladder control
- Stress response
- Social behavior
The CB1 receptor is located in the central nervous system with minor expression in the peripheral system. The CB2 receptor is located in the periphery mostly in the immune cells and the gastro intestinal tract. There may be other receptors with minor functions in the ECS.
Anandamide and 2-AG are the dominant endogenous cannabinoids. They act as neurotransmitters and bind to the CB1 & CB2 receptors respectively.
What Are Cannabis Based Medical Products (CBMPs)?
Over the counter CBD is made from hemp cultivars that contain less than 0.2% THC. CBMPs on the other hand are intended for therapeutic use and consequently may contain higher amounts of the psychoactive compound THC.
CBMP has been defined as:
- Contains cannabis resin and is not dronabinol or its derivatives
- Is intended for medicinal use in humans
- Is an ingredient in a medicinal substance
For the MHRA and Home Office to approve a CBMP the CBD: THC ration has to be declared and certificate of analysis produced. CBMPs are schedule 2 controlled substances and are therefore subject to the restrictions and regulations applicable therein.
Full Spectrum Vs Broad Spectrum Vs Isolate
CBD can come in three forms; full spectrum, broad spectrum, or isolate. Full spectrum CBD contains a full range of phytocananbinoids (including THC), terpenes, and flavonoids. This means that it offers full entourage benefits.
Broad spectrum CBD contains a range of phytocannabinoids (excluding THC), flavonoids, and terpenes. It has 0% THC and is therefore completely non- psychotropic.
CBD isolate is made up of pure CBD with no added phytocannabinoids, terpenes, or flavonoids.
Licensed Cannabis Based Products in the UK. So far there are two cannabis based products that have been licensed for public use in the UK: Sativex and Epidiolex. Sativex contains CBD and THC in a ratio of 1:1 and is used in the treatment of spasticity and MS. Epidiolex contains 98% CBD and is used in the treatment of intractable childhood seizures. Nabilone is a synthetic form of cannabinoid that has antiemetic properties. It is used in the management of nausea and vomiting related to chemotherapy.
Is CBD Safe?
The guideline referred to a 2018 World Health Organization (WHO) report that stipulated that CBD is safe and well tolerated even when consumed in high doses. There is no evidence of severe side effects or addiction related to CBD use that have been documented.
What Are The Indicated Uses of CBD?
CBD has the following properties:
- Anti- inflammatory
- Anti- anxiety
- Neuro protective
- Anti- psychotic
The strongest evidence for the therapeutic benefits of CBD is in the management of severe forms of childhood seizure. Most of the research on CBD is pre- clinical. However, there are ongoing phase 2 & 3 clinical trials that are ongoing in the treatment of schizophrenia, tumor reduction, drug dependence, PTSD, and pain conditions.
How Is CBD Consumed?
CBD can be consumed as below:
- Orally- absorption through this method is slow and erratic because the CBD needs to go through the digestive process. Bioavalability is reduced to about 6%. Plasma concentrations peak after 1-2 hours and may last for up to 6 hours.
- Sublingual- CBD can be consumed through the sublingual route that is beneath the tongue. This region is highly vascularized and hence absorption is enhanced.
- Intranasal- CBD sprays are good for nausea and vomiting or oral mucositis
- Vaping or inhalation- this method speeds up the onset of action and increases the bioavailablility of CBD. The CBD peaks in plasma in about 15 minutes and will last for 3- hours.
- Topical- the CBD is applied directly to the skin which is richly supplied with endocannabinoid receptors. Transdermal patches allow the CBD to be delivered steadily while minimizing chances of adverse effects.
How To Dose CBD
CBD dosing is affected by individual factors such as total body fat percentage, genetics, metabolism, age, and tolerance. CBD is extracted through the kidneys and those with kidney problems need to be cautious when medication on CBD.
A starting dose of 10mg per day is recommended for naïve patients. This can be increased to about 60mg over a 4 week duration as the effects are observed. Patients may need help in calculating how much CBD is in 1 mL of CBD oil.
CBD Drug Interactions
CBD interacts with drugs that are metabolized through the cytochrome p450 pathway. This includes drugs such as cimetidine, omeprazole, azithromycin, isoniazid, and sodium valproate. However, this is unlikely to happen when CBD is consumed in low doses such as 50-100mg of CBD daily. Patients taking antiepileptics, immunosuppressants, or anticonvulsants may need to consult with their healthcare providers before starting on CBD treatment.
Does CBD Cause Side Effects?
So far data has shown that CBD has a wide safety margin with low levels of toxicity even when consumed in very high doses. Somnolence and sedation may occur in high doses of CBD.
That information is quite a handful but very helpful at the same time. It is almost everything that clinicians need to know about CBD, at least for now.