An Honest Look at CBD
Around the world, governments are reconsidering their position on cannabis and a related product, cannabidiol (CBD).
Scroll through celebrity Instagram feeds, and you may well see pictures of their latest love—of CBD-infused everything. Gwyneth Paltrow, Morgan Freeman, Jennifer Aniston, Montel Williams, Kim Kardashian and Martha Stewart are among the outspoken advocates. Busy Philips says it helps with anxiety. Kristen Bell and others claim it helps ease pain, whether workout-related back pain or discomfort from walking the red carpet in sky-high heels. And Martha Stewart and Willie Nelson are each marketing their own line of CBD-infused products for pets.
Since medical and recreational cannabis use has once again been legalized in parts of the world, the market for related products is exploding. Cannabidiol, or CBD, is a nonpsychoactive chemical found in the Cannabis family of plants, which includes what are commonly known as hemp and marijuana. It’s the current darling of the alternative-medicine world, with CBD-infused candies, coffee, beer, smoothies, bath bombs, facial serums, textiles, lotions, dog treats and even hamburgers flooding the market, each with claims to calm everything from asthma and Alzheimer’s to schizophrenia and shingles.
Thousands of personal testimonials proclaim the benefits of CBD, but is this just the placebo effect at work? At this time it’s often hard to tell, because most of these products have not been tested under rigorous study conditions. Limited research shows that CBD may help with some seizures and insomnia and that it has reduced pain and inflammation in animals, but also that it can raise the levels of blood-thinning drugs such as warfarin, which causes its own set of problems.
As with many current social issues and debates, this one is multifaceted. Cannabis has been recognized for millennia as a plant with medicinal value, but even a cursory look at its recent history reveals an ugly side of human nature, whether in the form of profiteering or politicking or panic-mongering. On the other hand, you’ll also find touching stories of real people seeking and finding help. In either case, the appeal to emotion can be strong.
What’s the best approach to navigating what is still a hugely contentious issue?
Little Charlotte Figi tugged heartstrings worldwide in 2013 when CNN ran a story about her parents’ tireless search for anything to relieve her convulsive seizures—as many as 50 each day. Charlie, as she is affectionately known, was only 3 months old when the first of her prolonged seizures prompted a series of tests that eventually pointed to Dravet syndrome, a rare form of epilepsy that begins at a very early age, negatively affecting growth and development. For years she was prescribed progressively stronger medicines along with dietary changes, all leading to failure, disappointment and finally desperation. Her father, Matt, left his military career as a Green Beret to better help his daughter, who had a feeding tube and needed constant assistance with the activities of daily life. Side effects of the treatments were taking their toll on Charlotte—bone loss, compromised immune system, behavioral problems—yet the seizures continued. Finally doctors informed the family that there was nothing more they could do.
With nowhere left to turn, the parents began their own search for anything that showed a tiny bit of hope for little Charlotte. Her mother, Paige, explained: “I had heard of a California parent successfully treating an epileptic child’s seizure with cannabis, and because we live in Colorado, another state with legalized medical marijuana, I got busy doing research. I spoke with parents, doctors, scientists, chemists, marijuana activists, growers, medical marijuana patients, lawyers, and dispensary owners.”
“The literature was confusing, with some papers suggesting that marijuana appeared to help seizures, and other papers suggesting that seizures got worse.”
Having exhausted other options, Paige approached Charlotte’s doctors as well as people in the marijuana industry. But since Charlotte was so young—only five years old—they all discouraged treatment with medical marijuana. The desperate parents finally did get state and medical approval, however, and began administering low doses of an extract derived from a high-CBD strain of cannabis. Their daughter went from having more than 300 seizures per week to a full week without a single one.
Paige needed to locate a supplier who could fill Charlotte’s ongoing needs and contacted Colorado cannabis breeders Joel Stanley and his brothers. After another month of success, she weaned her daughter from other medications. Still needing to be convinced that CBD was responsible for the improvement, she experimented with reducing and even eliminating Charlotte’s cannabidiol, but the seizures returned each time. There was no doubt that the CBD-heavy medication was working.
In a 2014 article in the journal Epilepsia, Paige noted that “20 months after starting what the Stanley Brothers would eventually dub ‘Charlotte’s Web’ (CW), Charlotte has only 2–3 nocturnal GTC [generalized tonic-clonic] seizures per month, is feeding and drinking orally and on her own, sleeps soundly through the night, and her autistic behaviors (self-injury, aggressiveness, self-stimulating behavior, poor eye contact, and poor social interaction) have improved. She has had only one episode of autonomic dysfunction associated with Dravet syndrome in the same time period. She is finally walking and talking again.”
As encouraging as her results were, there’s a sad epilogue to Charlotte’s story. She died on April 7, 2020, having been hospitalized for (possibly COVID-19–related) breathing problems and pneumonia, followed by seizures and cardiac arrest. She was only 13, but her journey has given hope to other families who are trying to find help for their epileptic children.
Emotionally we may respond to all of this with a sense of wonder that cannabis is still so hotly debated, but not everyone has met with such astounding success. The reality is that while medicinal use of cannabis has been in practice for thousands of years, it is not without drawbacks.
An Unfinished Story
In addition to its medicinal properties, cannabis has long been recognized as a narcotic. This, at least in part, led to it being outlawed in many countries early in the 20th century. In an interesting twist, however, CBD extracted from Cannabis sativa has shown promise in treating substance-use disorder, as it may inhibit both the reward-facilitating effect of drugs (including cannabis itself) and the reoccurrence of drug-reward memory. Early research shows that alcohol-, opiate-, nicotine- and psychostimulant-use disorder may also be treated with CBD, though further studies and clinical trials are needed.
Similarly, although CBD has proven beneficial in treating children like Charlotte with drug-resistant epilepsy, its long-term effect on the developing nervous system in children and adolescents is not yet known, so researchers can’t say how safe it is.
A 2015 metastudy of CBD’s effect on neuropsychiatric disorders shows its potential as an acute treatment for anxiety, but it, too, stresses the need for further study to establish its safety in chronic, or long-term, dosing. The report emphasizes the paucity of fact-based conclusions: “Relatively few relevant studies exist, with mixed results, including both anxiolytic [anxiety-inhibiting] and anxiogenic [anxiety-causing] outcomes.”
A 2017 study showed that when individuals took CBD to reduce anxiety before public speaking, the reaction varied based on the amount they took. But contrary to what may have been the expected outcome, higher doses (900 mg, far more than what one would normally take) were less effective than the medium dose (300 mg). The smallest dose (100 mg, still very high compared to typical consumer levels) was ineffective. These therapeutic-level doses are not typically available in over-the-counter products, which generally provide between 10 and 50 mg of CBD in capsule form.
This may sound like Goldilocks looking for the dose that’s “just right,” but the fairy-tale ending isn’t happening just yet. Although CBD itself doesn’t seem to have many harmful side effects, there’s much more to consider, including how each form of the product interacts with the body, and how much is bioavailable. What the skin absorbs via bath bomb, oil or lotion is very different from what is available via vaping, suppositories, capsules or edibles. Researchers simply don’t yet know how the body responds to all the different ways of using CBD.
Too Many Unknowns
Tests on 84 CBD products from 31 companies revealed that only about a third were labeled accurately. Over 20 percent actually contained THC, which could cause users to get high, despite the fact that many seek out CBD specifically to avoid any such psychoactive effect.
As an example, two children who were given daily doses of CBD to treat Dravet syndrome were apparently intoxicated by THC in the oil, and the frequency of their seizures increased. This continued until the caregivers switched to a different CBD oil. Some producers now extract CBD from hemp, which is naturally lower in THC and higher in CBD than marijuana. Because CBD production is not closely regulated, however, consumers have no guarantee of the quality or safety of the products they buy, despite what labels or clever marketers may claim.
“Part of the challenge of understanding why cannabis has apparently contradictory effects in epilepsy likely has to do with the complexity of the plant itself. Cannabis sativa has 489 known constituents, only 70 of which are cannabinoids.”
But it’s not just the amount of CBD or THC in the products that raises concerns. Cannabis can do a remarkable job of mopping up heavy-metal contamination in soil, holding promise for cleaning radioactive spills and industrial waste. Of course, cannabis plants grown for human consumption can also soak up any heavy metals and contaminants in the soil. That means pesticides, herbicides and even radioactive heavy metals can be hiding in cannabis products.
Other worries include the addition of dangerous synthetic cannabinoids (to boost a psychoactive effect) and the residue of toxic solvents used for CBD (or THC) extraction. In the spring of 2018, 164 people were hospitalized and four died in Illinois from using synthetic cannabinoids, with another 70 hospitalized in Connecticut later that year.
The lack of regulatory oversight makes it very easy for contaminated cannabinoid products to slide into the marketplace, whether intentionally or not.
Nutraceutical or Pharmaceutical?
Ziva Cooper, director of research at UCLA’s Cannabis Research Initiative, agrees that more CBD-related research is needed but explains that a few obstacles stand in the way of quality studies. One is a near-total federal ban on growing cannabis, even for testing. Cooper, a member of the committee that drafted the 2017 National Academy of Sciences report on cannabis, explains that there are “regulatory barriers associated with the Schedule I classification of these drugs and the lack of funding opportunities to support research, which needs to be done to address both the therapeutic and adverse effects of cannabis and cannabinoids.”
“Schedule I” is the US government’s most restricted and regulated classification for drugs, reserved for substances considered to have a high potential for abuse and no currently accepted medical use. Other drugs in this schedule include heroin, lysergic acid diethylamide (LSD), ecstasy, methaqualone and peyote. As a result, most research institutions risk losing federal funding if they conduct research on cannabis products, thereby further limiting the studies that can be done. In addition, the Schedule I classification means there’s a shortage of pharmaceutical-grade material, despite the fact that CBD products are widely available—which suggests that what is marketed to consumers may not be of the quality they would knowingly consume.
In the fall of 2018 the first FDA-approved prescription drug containing CBD—strawberry-flavored Epidiolex—was released to the public for treatment of seizures associated with certain severe forms of epilepsy. But just because it’s a plant-related pharmaceutical doesn’t mean it doesn’t have side effects. Among those reported are drowsiness, lethargy, fatigue, nausea, loss of appetite, diarrhea, liver problems, sleep disorders, infections, even suicidal thoughts and actions.
Most medicines, of course—traditional or otherwise—can be contaminated or have adverse effects. So should CBD products go into wider production? Harvard Health, a publication of the Harvard Medical School, quotes Peter Grinspoon, a primary care physician at Massachusetts General Hospital: “I think CBD is likely safer than many other treatments people use for pain, insomnia, or anxiety.” Others, however, are not as quick to promote the trend. Cooper shares her concerns on the UCLA Health website: “What we’re seeing is the market is moving faster than science. Also, public policy has moved ahead of the research. Medical cannabis laws are being enacted in the absence of data. This is precisely the reason why we need to start engaging in rigorous science to understand the implications of the proliferation and accessibility of these products.”
“The evidence discussed in this report suggests that cannabis has both therapeutic value and public health risks. . . . To ensure that policy makers are better informed to make decisions . . . , an objective and evidence-based analysis of cannabis policy is necessary.”
The matter gets more complicated. Some consider CBD a food, others a drug, and its legal status is in flux not just in America but around the world. Claims about its powers abound, and for as long as it’s in vogue and there’s money to be made, marketers will ride the wave of popularity and sell commercialized CBD both as a superfood and a cure-all. But buyer beware: just because it looks like a celebrity has endorsed something, that doesn’t mean it’s true. Unscrupulous scammers have used the likenesses of Mehmet Oz, Phil McGraw, Montel Williams and Tom Hanks to sell CBD-enhanced products. About his alleged endorsement, Hanks warned “FRAUD! INTERNET FAKE! Just so you know” on his Instagram feed. Companies know that celebrity endorsements work, and unethical marketers will fabricate all sorts of claims in an effort to sell their products.
Just like some of the “snake oils” of the past, there may well be truth to some of the claims. But it’s hard to be objective and find that truth, especially if you’re desperately hoping and searching for relief of debilitating health issues. For now, though, the bottom line is that we simply don’t know enough about CBD and its interactions with the body and brain to know just how effective—or safe—it really is.
In the face of such uncertainty, wisdom must override emotion. In the end, each one of us is responsible for sorting fact from pseudofact and outright fiction. We also need to assess, to the best of our ability, whether arguments for and against CBD are driven by fear, hype, hysteria or profit, or by a genuine desire to benefit others. When the latter approach prevails on both sides, we will be well equipped, as consumers, to make a wise, informed and unemotional decision on its use.