CBD is a popular alternative treatment for conditions like anxiety and pain. But exactly what is it and how do you use it? Learn more in our CBD Guide. Pharmacist’s Guide to CBD Oil ABSTRACT: Cannabidiol (CBD) is becoming more prevalent, and pharmacists must be knowledgeable about these products in order to counsel patients effectively. CBD CBD has been touted to help with sleep, anxiety, pain, and more, and there are myriad ways to take it. But does CBD work? Is it safe? We’ve got answers.
The Complete Guide to CBD: Everything You Need to Know About Cannabidiol
Cannabidiol (CBD) is one of the natural compounds found in the cannabis plant. Because it does not produce a “high” feeling, CBD has grown incredibly popular in the past few years for the treatment of medical conditions like chronic pain , anxiety , inflammation , and epilepsy . It is readily available in various forms like CBD oil, lotions, tinctures, hemp flower, gummies, etc. This beginner’s guide to CBD covers everything you need to know, including types of CBD, dosages of CBD, the legality of CBD in the U.S., and more.
What Is CBD Oil?
Cannabidiol, also known as CBD, is an extract of the cannabis plant that is mixed with a carrier oil to form CBD oil. In states that have legalized recreational and medical cannabis, there are varieties of high CBD strains of cannabis that you can purchase at your local dispensary.
CBD only products are usually extracted from hemp as opposed to cannabis, because they contain higher amounts of CBD instead of the larger amounts of Δ9-tetrahydrocannabinol (THC) that are found in cannabis. To extract CBD oil from hemp or the cannabis plant, a CBD extraction machine is required. Solvents such as ethanol are also typically used in this process. New extraction methods for CBD oil, such as supercritical CO₂ , are now available and make cleaner, more purified CBD products. This is because it balances the temperature and pressure of the plant during extraction, eliminating the need for solvents.
Prescription CBD oil, called Epidiolex , can be safely administered by a doctor for children suffering from seizures due to certain epilepsies. CNN’s medical correspondent Doctor Sanjay Gupta hosted a documentary highlighting CBD for children diagnosed with epilepsy and seizures . In the documentary, Weed 4: Pot vs Pills , Doctor Sanjay Gupta emphasizes the medicinal value of cannabidiol.
Therapeutic Potential of CBD Oil
Many doctors and proponents of holistic and all natural medicine trust in the therapeutic component of CBD as an alternative medicine to reduce various symptoms to alleviate or play a potential role in the following conditions, according to the World Health Organization (WHO): “ nausea , inflammatory bowel and Crohn’s disease , anxiety, depression, psychosis, cancer , neuropathic pain , asthma, Alzheimer’s disease , Parkinson’s disease , rheumatoid arthritis , inflammatory disease, multiple sclerosis , cardiovascular diseases , diabetic complications , and infection.”
CBD is generally well-tolerated and has a good safety profile. Major studies from the scientific community continuously appraise the medicinal benefits of CBD. It is clearly evident that more research needs to be done to prove the effectiveness and long-term outcomes of this medicine. Our country can no longer rely on doctors continuously prescribing suboptimal or even addictive medications that aren’t giving patients relief.
The WHO reported in 2017 that no “public health related problems” have been connected to the use of pure CBD. The report adds that, “In humans, CBD exhibits no effects indicative of any abuse or dependence potential.” CBD is a generally safe option alternative treatment, as long as you consult your doctor to be sure that CBD won’t interfere with your other medications.
Potential Side Effects of CBD
However, CBD may also carry mild temporary side effects, including drowsiness, decreased appetite, nausea, vomiting, diarrhea, and abnormal liver function tests. Most of the abnormal liver function tests were reported to be reversible in the Epidiolex clinical studies with adjustment of CBD dose or seizure medication dose.
You should always learn how CBD products affect you before driving, operating machinery, or increasing your dose, as higher doses increase the probability of side effects. The efficacy, drug interactions, or long-term effects of cannabis or cannabinoids are not yet fully known, and may not be suitable for everyone. Thus, always talk to your healthcare provider first before taking cannabis or CBD products for any reason.
What Is the Difference Between CBD and THC?
Δ9-tetrahydrocannabinol (THC) is a chemical component that causes the intoxicating effects of the cannabis plant. However, high-CBD and low-THC strains of cannabis do not produce intoxication, but offer the ability to alleviate many ailments including seizures. These strains, such as Charlotte’s Web , highlight the medicinal characteristics of cannabis.
What Are Cannabinoids?
Cannabinoids are chemical compounds that naturally occur in the cannabis plant. Cannabis contains around 150 cannabinoids ; the two primary and most popular cannabinoids are THC and CBD. As cannabis research evolves, we are learning more about other cannabinoids like cannabigerol (CBG) , cannabinol (CBN) , and cannabichromene (CBC). These natural cannabinoids can play a major role in the endocannabinoid system, a system of the human body that was not in the limelight until recently and is still being explored.
The Endocannabinoid System
Although it is one of the oldest biological systems of the human body, you may have never heard of the endocannabinoid system . Our bodies come equipped with this entire system that is responsible for managing a multitude of physiological processes. The endocannabinoid system, or ECS for short, is a map of cannabinoid receptors located throughout the body.
The purpose of the endocannabinoid system is to regulate a variety of bodily functions such as mood, memory, fertility, appetite, hormones, and responses to pain or stress. In the end, the ECS helps our bodies maintain homeostasis or balance .
In fact, the discovery of the cannabinoids found in the cannabis plant led to the naming of the ECS. “Since the time when exogenous cannabinoids revealed their existence, the entire natural complex came to be called the ‘endogenous cannabinoid system,’ or ‘endocannabinoid system’ (ECS),” according to Dr. Bradley E. Alger in his 2013 paper published in Cerebrum .
In other words, endocannabinoids are the body’s natural endogenous cannabinoids. Endocannabinoids are neurotransmitters that activate the cannabinoid receptors of the ECS.
How Cannabinoids Interact With the ECS
However, we also react to exogenous (meaning external) cannabinoids like those found in cannabis. Phytocannabinoids, “ phyto” meaning plant-derived cannabinoids, also attach to our receptors that initiate a physiological response. Essentially, our receptors are the lock and cannabinoids are the keys that unlock feedback.
At this time, there are two known receptors in the ECS: CB1 and CB2. Both are dispersed all over the body; however, CB1 receptors are mostly found in our brain and nervous system, while CB2 receptors are condensed in our organs and immune system. Each of the two types of receptors are responsible for strategically keeping order of our immune and nervous system functions.
Emerging evidence indicates that cannabinoid receptors may bond with each other, and that cannabinoids may also interact with adenosine, opioid, serotonin, and dopamine receptor families. In due time, we’ll be able to learn more about our other receptors and their effects when more research is conducted.
Hemp CBD vs. THC CBD
Most are familiar with THC, the cannabinoid responsible for the intoxicating and euphoric effects of marijuana that causes “impairment.” THC’s molecular form is very similar to our bodies’ naturally occurring endogenous neurotransmitters.
Hemp and cannabis are the same species of plant, but hemp is federally legal and contains less than 0.3% THC content, meaning that it does not intoxicate users like most cannabis in the recreational market does. Essentially, the word hemp refers to low THC variations of the same plant. Another main difference between hemp and cannabis is the use of hemp for industrial purposes like the production of paper, building materials, skincare products, food, and clothing .
The Entourage Effect
There are hundreds of different types of organic compounds found in the cannabis plant. When ingested, virtually all of these cannabinoids and other compounds work together and produce a complete, well-rounded effect known as the entourage effect . Dr. Raphael Mechoulam, the founder of THC , conducted research in 1999 that introduced the concept of the entourage effect. Today, the term is used to describe how individual chemical components synergistically work together to produce superior effects and improve the cannabis experience.
So what else plays a role in the entourage effect? There are six main cannabinoids:
- Δ9-tetrahydrocannabinol (THC)
- Cannabidiol (CBD)
- Cannabigerol (CBG)
- Cannabichromene (CBC)
The last four are less popular but are beginning to get more attention. Terpenes are another component of the cannabis plant that create the scents of individual strains and are believed to contribute to the entourage effect. Cannabis researcher Dr. Ruth Fisher points out that terpenes can increase the body’s rate of absorption of cannabinoids . The entourage effect, in other words, is the idea that CBD is enhanced by the other cannabinoids and compounds found in cannabis and/or hemp derived plant medicine.
Is CBD Psychoactive?
The answer to this is a little complicated. CBD alone won’t produce an outright intoxicating response or get you high. In fact, CBD can be used to counteract the intoxicating effects of THC . However, it is important to note that CBD is technically psychoactive, meaning that it affects the mind.
CBD affects the mind in positive ways like alleviating stress and anxiety , boosting mood, improving depression and addiction as well as helping with sleep. These are just a few of its health benefits. It is more widely used for pain and inflammation . Some who are more perceptive of their physiology might feel a subtle uplift in their mood.
But it won’t be enough to cause a mind-altered state, reduced cognition, paranoia, or anxiety like THC can. CBD will not make you lose your control or even alter your behavior. Though, be aware that there are some risks depending on what products you use like supplements and medications.
CBD Is Psychoactive but Doesn’t Induce a High
Many people also believe that the word psychoactive automatically implies something bad or negative, but something that affects your mind is not always a bad thing. We consume many foods and compounds that have psychoactive properties without any adverse effects. Chocolate is one such example. Chocolate does have psychoactive properties, particularly dark chocolate. For example, both chocolate and CBD influence serotonin activity.
When individuals see the word “psychoactive,” they automatically associate it with the effects of THC. Due to this stigma, companies end up putting CBD under the “non-psychoactive” label. It also creates some distance from intoxicating cannabis strains containing high potency THC that are popular at recreational dispensaries.
You’ll want to become familiar with the differences between broad-spectrum CBD and full-spectrum CBD products, because full-spectrum products utilize the entire plant and have very little THC in them. And for CBD to be legal, it is required to have less than 0.3% THC. Although rare, those who are sensitive to THC might experience minimal intoxicating effects when using full-spectrum CBD goods. Broad-spectrum products have undergone processing that removes all THC compounds, therefore virtually eliminating the risk of feeling high. We cover different types of CBD oil in depth in the next section of this guide.
CBD Binds to Receptors Differently Than THC
While CBD won’t provoke an intense response from our CB receptors like THC, it will impact them and the way they operate. It’s not limited to just our CB receptors either! CBD can bind to other receptors in the body and influence them as well. For example, CBD has known effects on our serotonin receptors that reduce stress . While at the same time, it can also inhibit functions in others like our pain receptors.
Although this is all good news, the way in which the cannabinoid compounds interact with our brain is yet to be fully understood . Many studies are still underway while experiments exploring potential treatments are being tested on mice. Rest assured, while we may not have definitive evidence on a lot of aspects regarding CBD, its safety has been repeatedly confirmed and remains unchallenged.
Different Types of CBD Oil
If you’ve been following the recent CBD craze, you’ve likely encountered products on the market labeled as broad-spectrum, full-spectrum, or Isolate. These terms can be confusing for everyone, especially for beginners and curious folks alike. We are happy to enlighten you on the key differences in these descriptions and how to use CBD oil. We briefly touch on the subject in the video below, but let’s explore these terms in depth.
Full-spectrum CBD, or whole plant CBD, is created using the whole hemp plant, meaning that it still contains different components of the plant like multiple cannabinoids (CBD, CBN, CBG, etc.), terpenes, and flavonoids. THC is also present but still below 0.3% (otherwise it would not be federally legal).
A study published in 2018 in the journal Frontiers in Neurology analyzed medical records and patient surveys for those being treated with CBD for refractory epilepsy. The researchers found that “CBD-rich extracts seem to present a better therapeutic profile than purified CBD, at least in this population of patients with refractory epilepsy. The roots of this difference is likely due to synergistic effects of CBD with other phytocompounds (aka Entourage effect), but this remains to be confirmed in controlled clinical studies.” In the study, patients taking full-spectrum CBD needed lower average doses of CBD in comparison to those taking pure or isolated CBD.
Broad-spectrum products belong in a category that is somewhere between full-spectrum and isolates. While all of the organic plant matter is processed, the THC molecules are isolated and thoroughly excluded. Those that use broad-spectrum products are able to experience the benefits from the entourage effect, because all of the other collaborating cannabinoids and terpenes remain included in the product.
Isolate means that only the CBD compounds have been extracted from the plant. The original plant matter has been extensively refined to narrow down and separate molecules, so that the only thing left is CBD. Isolate is 99.9% pure CBD. Sometimes, additives like artificial terpenes and flavonoids are included to enhance the taste, smell, or consistency. Otherwise, there should be virtually zero traces of any other compounds in it.
Can I Fail a Drug Test by Taking CBD?
“Will I fail a drug test if I take CBD?” is a question we often hear (see the video below). Those who are subject to regular drug screenings such as federal employees often wonder if CBD will pose an issue for them. The answer is yes, depending upon the type of CBD product you ingest, cannabinoids can show up on a drug test.
It’s not unusual for CBD consumers to feel confused when the terms on the product labels aren’t generally well-known. Refer to the above section for the differences between full-spectrum, broad-spectrum, and isolate CBD. While it is extremely rare, full-spectrum CBD products have the ability to produce a positive result on drug tests that screen for THC.
Since all THC molecules are eliminated, broad-spectrum products are less likely to show up in routine drug testing and may be a good choice for those who want to refrain from consuming THC. CBD isolate is a great option for those who want to avoid the euphoric effects of THC or are concerned about passing a drug test, because the THC molecules have been virtually eradicated.
Best Way to Calculate Proper CBD Dosage
Are you one of the millions of people turning to the CBD market as an alternative or addition to prescription meds ? More Americans are substituting opioids with cannabis , which unlike opiate-based medications, are non-lethal and many find that they experience fewer side effects with CBD.
Between the years 1999 and 2017, drug overdoses killed 702,568 people in the United States and almost 400,000 of those deaths involved the use of opioids. This is according to the Centers for Disease Control and Prevention (CDC) , which claims that from 2015-2016, illicitly manufactured synthetic opioids like fentanyl killed more people than any other drug category.
Thankfully, cannabis may produce some of the same sedating and pain-relieving effects produced by drugs in the opiate class, causing a reduction in opioid use . CBD is being widely used as a natural and safe pain management treatment. In fact, a recent study published in the American Journal of Psychiatry revealed how CBD could even reduce opioid cravings and craving-related anxiety in a double-blinded, randomized placebo-controlled trial setting.
If you’re using CBD for another purpose, such as for anxiety relief or as a means of establishing proper overall health and wellness, the following information will be equally as important for you to absorb. But how do you take CBD oil? Read on to learn more about dosage considerations.
Important Dosage Considerations When Using CBD Oil
Now, we are going to talk about dosage and what is the optimal amount of CBD to use for you personally. While you can’t overdose from this cannabinoid, the likelihood of side effects increases with the dose. Determining the best CBD dosage generally depends on the following factors:
- Body weight: One milligram of CBD for every kilogram of body fat is a good starting point when trying it for the first time. The heavier the person, the more cannabinoids they will need in order to experience what a lighter person experiences with a lower dosage. If you have side effects, try reducing your dose and slowly working your way back up.
- Concentration: Pay attention to the potency of your CBD before consuming it. For example, dropping a one-milliliter tincture onto your tongue containing 1,500 mg of the non-intoxicating cannabinoid will provide you with around 50 mg of CBD.
- Tolerance level: Are you a chronic cannabis consumer? If so, or if you have been using CBD for a while now, keep in mind that your tolerance will be higher than a newbie, so you might need a stronger dosage.
- Desired outcome: The more pain or discomfort you’re in, the more CBD you’ll need to experience relief. Consider how you want to feel before consuming CBD and base your decision on this.
- Age: As we age, our metabolism tends to slow down and the number of prescriptions you’re on tends to go up. These factors may mean you would likely need lower doses of CBD.
- Medications: CBD is metabolized by the same enzymes responsible for degrading around 60% of prescription medications. In the clinical studies for Epidiolex , CBD caused increased levels of the anti-seizure medication clobazam, which caused adverse effects. However, these adverse events were generally mild and reversed by reducing the dose of either CBD or clobazam. Certain medication and CBD doses may need to be adjusted by your doctor.
In addition to the aforementioned guidelines for choosing a CBD dosage, you should pay attention to the concentration of whatever product you end up buying. Low potency would be in the range of 1-10 mg per serving, whereas a medium potency oil should deliver around 10-25 mg of CBD per serving, e.g. per capsule, per spray, per tincture, etc. Anything higher than this is considered highly potent.
Is CBD Legal?
CBD products are gaining popularity on their own aside from the legalization movement of cannabis worldwide. Times are changing in the cannabis industry as the U.S. federal government is taking the necessary steps to end the War on Cannabis. Effective September 28, 2018, the Drug Enforcement Agency (DEA) made a groundbreaking announcement:
“With the issuance of this final order, the Acting Administrator of the Drug Enforcement Administration places certain drug products that have been approved by the Food and Drug Administration (FDA) and which contain cannabidiol (CBD) in Schedule V of the Controlled Substances Act (CSA). Specifically, this order places FDA-approved drugs that contain CBD derived from cannabis and no more than 0.1 percent tetrahydrocannabinols in Schedule V.”
It’s important to be informed about the terminology behind these products. CBD that is derived from industrial hemp is federally legal in every state. However, each state sets their own laws regarding hemp as well as medical or recreational cannabis use. Check out this guide regarding CBD laws to see where your state stands in terms of CBD legality. In order to meet legal requirements, all CBD goods MUST contain less than 0.3% THC. Check out the next section for more information on the differences between cannabis and hemp.
Legalized CBD-Derived Medication
It is important to note that the pharmaceutical medication Epidiolex is the only CBD-based medicine approved by the Federal Drug Administration (FDA). Epidiolex itself is now no longer classified as a controlled substance by the DEA. Under the DEA’s Schedule V status, CBD is now classified as the least restrictive controlled substance.
Epidiolex is an oral solution that is supposed to treat seizures associated with Lennox-Gastaut syndrome and Dravet syndrome in children of two years and older. Recently in 2020, it was also approved for seizures associated with tuberous sclerosis complex in children over age one. Ever since the Food and Drug Administration (FDA) panel approved Epidiolex, people have been confused about the legal status of this substance.
Since CBD is a targeted medicine for the treatment of epilepsy and given to children to treat their seizures , the lack of intoxication makes CBD a perfect medicine for treating medical problems in children. For the first time in U.S. history, a hemp-derived medication won federal approval in the US.
What’s the Difference Between Legal Hemp and Cannabis?
There is a legal distinction between cannabis and hemp. Cannabis is typically bred for recreational dispensaries and is high in THC content, which provides inebriating effects. On the other hand, hemp is bred and grown for the industrial use of fiber as well as seed, and all hemp must legally contain below 0.3% THC. With hemp, there is no way to induce intoxication by consuming any reasonable amount of it. Hemp-derived CBD products are available to purchase in stores (not just dispensaries) and online.
All that being said, the 9th US Circuit Court of Appeals upheld a DEA rule that defines any cannabis extract as a Schedule I controlled substance if it contains one or more cannabinoids, a definition that CBD seems to fit.
“Contrary to some early reports, this ruling does NOT classify hemp-derived cannabidiol (CBD) as a controlled substance, nor does it signify that the popular hemp product is federally illegal…In short, the DEA’s ‘marijuana extract rule’ does not apply to hemp or derivative products such as hemp-derived CBD. Period…Anybody out there that says the law is definite one way or another is lying.” – Jonathan Miller, The Hemp Industry’s Lawyer
Until the situation becomes clearer, it’s best to check out the laws in the city or state in which you live.
Can I Purchase CBD Online?
Where to buy CBD oil is a question that many readers ask us. Just about anyone in the U.S. can purchase CBD derived from hemp online right now. There are lots of CBD products available such as oil, lotion, coffee, shampoo, candy, beauty products , and vape juice.
How Do I Know if the CBD I’m Buying Is Legitimate?
If you don’t live in a state in which cannabis is legal, you may have some difficulties with finding legitimate CBD products. Whenever you’re buying online, make sure to do some due diligence and read some reviews, because there are no required testing regulations to see if the product is effective or not.
Always look for the “ Certificate of Analysis ” (COA) to ensure purity and potency. These results should detail the levels of various cannabinoids, terpenes, and solvents used in the manufacturing process. It also helps ensure the product is free of harmful contaminants and unwanted ingredients like pesticides and heavy metals. Avoid buying hemp products from overseas, as they are more likely to contain such contaminants. You can also look for any additional certifications like “ USDA Certified Organic Hemp ” or “ BSCG Certified ” for more credence.
Is It Legal to Ship CBD Products Across State Lines?
Yes, there are companies that comply with the 2018 Farm Bill , and they can ship their products anywhere in the U.S. with the right commercial licensing. This bill differentiates cannabis from industrial hemp and allows the cultivation of hemp within the United States.
As of April 2021 , there are currently 36 U.S. states that have medical marijuana programs. Note that some of these states only allow CBD in oil form containing a low percentage of THC, and some only allow CBD oil for the treatment of pediatric epilepsy as part of their medical cannabis programs. As of 2018, the following states have no rules regarding whether CBD comes from cannabis or hemp as well as any laws limiting CBD:
- Washington DC
The following states have medicinal cannabis programs that only allow CBD oil:
- Texas (this will be changing to allow 5% THC oil beginning in December 2021)
Medicinal Uses for CBD
CBD is an option for those who need relief from their medical ailments without the intoxicating effects of THC or other drugs like opioids. CBD is a chemical compound that occurs naturally in the cannabis and hemp plants and is not a mind-altering substance , unlike the plant’s well-known intoxicating constituent THC.
While you can’t overdose from CBD, it can provide plenty of therapeutic effects for the human body. Studies show that extracts with a high-CBD content tend to work well as a candidate anxiolytic (meaning that it reduces anxiety), antidepressant , and antipsychotic .
What Are Some of the Conditions That Improve With CBD Oil?
Below are some of the many conditions for which CBD is used to alleviate symptoms:
Can CBD Replace Prescription Medication?
Thanks to the pain relieving effects of CBD, some patients are able to stop taking addicting opioid medications for their chronic pain. According to Consumer Reports, CBD works to fight inflammation (it is an anti-inflammatory), addiction, and anxiety. Speak to your doctor and make sure that taking CBD won’t interfere with any of your prescription medications or supplements.
Unlike most pain medications that are often prescribed by doctors, such as Hydrocodone (prescribed 127,859,000 times in 2017), Oxycodone/OxyContin (16,440,000), and Morphine sulfate (9,658,000), CBD consumption is by no means limited to consuming a capsule. CBD comes in many forms like CBD edibles , beverages, topicals, tinctures, and more. You can read more about ways to take CBD oil in the next section.
It’s always important to be well informed on how remedies work and the effects that they may have on your body. Again, speak with your doctor before using CBD, especially if you are currently taking other medications, and see if it’s the right thing for you.
Best Ways to Take CBD
CBD oil – whether in its isolated, full-spectrum, or broad-spectrum form – can be baked into edibles for slow-releasing effects, taken sublingually (under the tongue) in the form of a tincture, vaporized for fast symptomatic relief, spritzed onto the tongue for quick absorption into the bloodstream or consumed in the form of a suppository or capsule. CBD can even be applied topically to affected muscles or areas of skin for localized relief in the form of topicals and lotions.
The best way to take CBD oil is going to be different for each individual depending on their preferences and needs. CBD can be delivered to your body in multiple ways, ranging from applying topical cream over your skin to eating CBD infused products. High-quality CBD products are available for users from high-quality chocolates to refreshing infused beverages. There are endless possibilities with infused foods and drinks ranging from CBD coffee, to CBD candy, and even hemp seeds for smoothies.
Benefits of the Different Types of Ways to Consume CBD
- Edibles: Many patients choose edibles for medicating with CBD for their slow-releasing and-long lasting effects. Plus, there are fun and discreet options for consuming CBD like candy, chocolate, and gummies.
- Lotions:Patients struggling with skin conditions like psoriasis and acne, as well as aches and pains in the muscles and joints, may prefer to use lotions and topicals containing CBD. These can be applied directly to sore muscles as well.
- Tinctures : Tinctures are an excellent option for those who need fast relief. They are used sublingually, meaning that they are placed under the tongue for faster absorption. Tinctures can avoid the cannabinoid-reducing “first pass” effect in the liver. They are available both as sprays or as tinctures (which are applied with a dropper).
- Vaping: Vaping CBD is one method that many choose for fast relief of symptoms. Additionally, some say it helps them quit smoking and that they enjoy vaping flavored CBD oil. Vaping and other inhalational methods may carry unknown health risks and may not be suitable for those with heart or lung conditions.
- Drinks: Like edibles, CBD drinks are a fun and discreet way to enjoy the benefits of CBD. With the rising popularity of CBD products, there are numerous drink options available, like soda, coffee, seltzer, and tea. Some cafes even offer CBD as an optional add-in for smoothies.
We emphasize doing your due diligence and making it a point to only purchase CBD products that have been thoroughly lab tested and have a Certificate of Analysis (COA) available.
To summarize, cannabidiol (CBD) is one of the hundreds of compounds found in the cannabis plant. The substance has a wide range of medicinal and therapeutic effects that have been shown to be beneficial for different medical conditions, including insomnia , chronic and neuropathic pain , depression, anxiety, and even for children with epilepsy.
Remember to speak with your doctor before using CBD to learn if it’s right for you, especially if you are taking prescription medications. At Veriheal, we can set up an appointment for you with a medical marijuana doctor or a cannabis coach to learn more about how cannabinoids like CBD and THC may be able to alleviate the symptoms of your condition(s).
Note: The content on this page is for informational purposes only and is not intended to be professional medical advice. Do not attempt to self-diagnose or prescribe treatment based on the information provided. Always consult a physician before making any decision on the treatment of a medical condition.
This guide is a compilation of blog posts written by Chane Leigh , Lo , Anthony Dutcher , and Bethan Rose .
Pharmacist’s Guide to CBD Oil
ABSTRACT: Cannabidiol (CBD) is becoming more prevalent, and pharmacists must be knowledgeable about these products in order to counsel patients effectively. CBD laws and regulations are determined at the state level in the United States. Non–FDA-approved CBD products are not regulated and may contain harmful chemicals. Pharmacists must counsel patients on where and how to obtain products and to check the amount of CBD and delta-9-tetrahydrocannabinol in the product. CBD has numerous drug interactions that should be evaluated by a pharmacist. CBD is most promising for treatment-resistant seizures, and more research is necessary to evaluate its use for other indications. Sativex is currently being investigated in the U.S. for treatment of spasticity associated with multiple sclerosis and schizophrenia. In general, more studies of CBD are needed.
Cannabidiol (CBD) is gaining popularity across the United States. Pharmacists must be able to answer patients’ questions about CBD and make recommendations. This article will provide specific information about CBD, including laws, how to select a non–FDA-approved CBD product, indications for use, side effects and warnings, drug interactions, dosing and directions, pharmacokinetics, and the future of CBD oil. After reading this article, pharmacists should feel confident about counseling patients about CBD and recommending CBD products.
Laws Concerning CBD
CBD was first isolated from the Cannabis sativa plant in the 1930s. CBD is a nonpsychoactive part of the plant, whereas delta-9-tetrahydrocannabinol (THC) is the major psychoactive part of the plant. In the 1970s, researchers evaluated CBD as a pharmacologic agent. 1 Epidiolex, a 100 mg/mL oral solution with less than 0.01% THC, became the first FDA-approved CBD-containing drug in June 2018. 2 The drug is Schedule V and indicated only as an anticonvulsant for Lennox-Gastaut syndrome or Dravet syndrome in patients aged 2 years and older. 3
In December 2018, the Agriculture Improvement Act, which removed hemp from Drug Enforcement Administration (DEA) regulation as a controlled substance, was passed and signed into U.S. law. Hemp is defined as a cannabis plant that contains no more than 0.3% THC. (In contrast, marijuana has a higher THC.) Hemp is now regulated by the U.S. Department of Agriculture and is legal in all 50 states. Laws and restrictions regarding the selling of hemp products vary by state, making it questionable to travel with CBD products. 2
U.S. laws and regulations concerning CBD are determined at the state level. Currently, 33 states have legalized CBD use for medical purposes, and 10 states (Alaska, California, Colorado, Maine, Massachusetts, Michigan, Nevada, Oregon, Vermont, and Washington) and the District of Columbia have legalized marijuana for recreational use. In states such as New York, Minnesota, and Connecticut, pharmacists are required to dispense the products in authorized dispensaries. Marijuana-derived CBD oil is still considered illegal under the Controlled Substances Act in accordance with the DEA’s classification of marijuana as a Schedule I substance. 2
Selecting a Non–FDA-Approved CBD Product
Pharmacists must educate patients about how to select an appropriate non–FDA-approved CBD product. These products are not tested for safety, efficacy, or quality. 4 The main concerns in picking a non–FDA-approved CBD product are that it may contain harmful chemicals and may not accurately list the correct amounts of CBD and THC it contains. These products could contain harmful contaminants (e.g., pesticides, heavy metals) or have high levels of THC, which would result in a positive urine drug test. 5 The patient should be advised to obtain CBD products from a medical dispensary because these products are regulated. The patient should also consider ordering products from states where CBD is legal because more testing is done in those states. When selecting a product, the patient should check the label to see if it lists the amount of CBD in each dose. 5,6 The manufacturer should provide a Certificate of Analysis, which shows an independent laboratory’s assessment of the product’s potency and the presence of contaminants. 5 When assessing quality, the patient should look for the Hemp Authority seal, which means that the product is legal and the manufacturer is adhering to quality standards. 7
Indications for CBD
As consumer demand in the U.S. has risen, along with the number of dispensaries, the number of studies addressing the therapeutic effects of CBD has increased. The studies performed, however, are insufficient; large randomized, placebo-controlled trials need to be conducted. CBD seems most promising for treatment-resistant seizures. There is limited evidence concerning the use of CBD for psychotic symptoms in Parkinson’s disease and for anxiety related to public speaking. CBD has not been proven effective for pain, nausea, or depression. 4 THC, conversely, is thought to be effective for these conditions because it has a different mechanism of action. THC activates the CB1 and CB2 receptors in the brain, and CBD does not. As mentioned previously, CBD does not have psychotropic effects and THC does. These differences are believed to account for the different uses of CBD and THC. 7,8
Patients with early-onset epilepsy who are resistant to conventional therapy may benefit from CBD oil. A trial that investigated the effect of CBD on drop seizures of Lennox-Gastaut syndrome found that CBD 10 mg/kg/day or 20 mg/kg/day, when added to conventional therapy, led to a greater reduction of drop seizures compared with placebo. 9 The most common adverse reactions were somnolence, decreased appetite, and diarrhea. Specific adverse events from CBD included elevated liver aminotransferase concentrations. 9
Clinical findings on the use of CBD oil in Parkinson’s disease (PD) remain unclear. Past studies have evaluated CBD’s efficacy in minimizing nonmotor symptoms of PD, such as cognitive deficits, sleep disturbances, psychosis, depression, and anxiety. 10 The neuroprotective properties of CBD have been studied in animals with PD, with results indicating that CBD appears to reduce psychotic symptoms. 11 Although patients with PD have reported fewer sleep disturbances as well as improvements in quality of life, treatment in humans requires further investigation on a larger scale, with longer durations and more standardized dosing. 12 Most studies have used combinations of CBD and THC extracts, including nabilone, a synthetic CB1 receptor agonist. CBD dosages of 150 mg/day for 4 weeks and titrated by 140 mg/week were found to be safe and well tolerated and did not worsen motor function. 10
More evidence is needed to support the use of CBD for anxiety. Studies have found that CBD 300 mg may be effective for anxiety related to public speaking, and doses of 400 mg to 600 mg may help patients with social anxiety disorder and public speaking–related anxiety. Studies are inconclusive concerning the utility of CBD for anxiety. 13
Side Effects and Warnings
Studies have reported various properties and potential benefits of CBD. Some undesired side effects of CBD use are decreased appetite, dry mouth, diarrhea, dizziness, drowsiness, fatigue, lightheadedness, orthostatic hypotension, psychomotor slowing, sedation, somnolence, weight loss, and increased risk of liver injury with dosages of 20 mg/kg/day or the use of clobazam or valproate. Monitoring of liver enzymes, weight, and cognitive function may be warranted. CBD can pass through the placenta, so it is recommended that CBD be avoided during pregnancy and while breastfeeding. Because CBD oils may contain trace amounts of THC, operating heavy machinery and driving should be avoided when treatment is initiated. 1
CBD is metabolized in the liver, mainly by CYP2C19, CYP3A4, and UGT. This can lead to interactions with prescription drugs, OTC medications, and herbal supplements. 1,14
The inhibition of CYP2C19 by CBD can increase levels of carisoprodol, citalopram, clopidogrel, diazepam, phenytoin, proton pump inhibitors (PPIs), valproic acid, and warfarin. As a strong CYP3A4 inducer, CBD may lessen the efficacy of amlodipine, atorvastatin, buprenorphine, bupropion, diltiazem, eplerenone, fentanyl, loperamide, midazolam, paclitaxel, pioglitazone, sildenafil, solifenacin, tamsulosin, testosterone, topiramate, zolpidem, and other 3A4 substrates. 7
More serious effects may occur with concomitant use of central nervous system depressants, such as barbiturates, benzodiazepines, fentanyl, morphine, and propofol. These effects are the result of the synergistic effects of sedation and hypnotic effects at high doses. Increased sedative effects may also be seen with herbal supplements, including kava, melatonin, S-adenosylmethionine, and St. John’s wort. 13,14
Other interactions to be aware of are presented in TABLE 1.
Dosing and Directions
In unregulated dispensaries, CBD oil sold comes in a sublingual formulation known as CBD tincture and is generally available in 30-mL bottles with dropper caps. 15 A bottle costs approximately $20. The concentration of the tincture ranges from about 1,500 mg to 3,000 mg per bottle. If a drop equals 0.05 mL, one bottle contains approximately 600 drops of CBD oil. Drops are usually placed under the tongue, and the patient should let the oil absorb into the lining of the mouth, without swallowing, for 30 seconds to 1 minute. Capsules and gummies are also available. 15
As noted earlier, Epidiolex (CBD) is an FDA-approved oral solution for treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome. The cost of Epidiolex is approximately $2,708 per month. It is supplied as 100 mL of solution containing CBD 100 mg/mL. For both indications, the initial starting dosage is 2.5 mg/kg orally twice daily for 1 week. The dosage may be titrated weekly in increments of 2.5 mg/kg twice daily to a maintenance dosage of 5 mg/kg twice daily. The maximum dosage is 10 mg/kg twice daily or 20 mg/kg/day. Gradual tapering is recommended when Epidiolex is discontinued. 3
Starting at a low dosage is recommended for elderly patients and patients with moderate or severe hepatic impairment. The dosage should be 1.25 mg/kg to 5 mg/kg twice daily or 0.5 mg/kg to 2 mg/kg twice daily, respectively. 3
CBD reaches its maximum concentration in 2.5 to 5 hours. High-calorie and high-fat meals can increase the maximum concentration of drug fivefold and the AUC fourfold. 14 Owing to the first-pass effect, CBD is poorly absorbed, with a bioavailability of 13% to 19%. Better bioavailability has been reported with inhaled CBD (11% to 45%). CBD is 94% protein bound; therefore, interactions may occur with other highly protein bound drugs or in patients who have abnormal albumin levels. The volume of distribution is 20,963 L to 42,849 L, meaning that the drug is largely distributed into the tissues. CBD is metabolized by the gut and primarily by the liver. Epidiolex has an active metabolite, 7-OH-CBD, and is a 2C19 and 3A4 substrate and inhibitor of 2C19, 1A2, UGT1A9, and UGT2B7. Its elimination half-life is 56 to 61 hours. CBD is excreted primarily in the feces and urine. 3
The Future of CBD
Sativex (nabiximols) is an oromucosal spray that contains CBD and THC in a 1:1 ratio. The active ingredients are absorbed sublingually or buccally. Sativex is currently under investigation in the U.S.; however, more than 25 countries worldwide have approved Sativex for the treatment of spasticity associated with multiple sclerosis. Sativex is also being researched for potential treatment of schizophrenia and other conditions. 16
The Pharmacist’s Role
Some pharmacists are hesitant to get involved with CBD. Prosecution by federal law could lead to severe consequences, including fines, imprisonment, or loss of DEA registration for pharmacies, ultimately stripping them of their ability to dispense controlled substances. If U.S. laws and regulations were more uniform across states, many of the concerns surrounding CBD would be eliminated. Until then, patients must use caution when selecting a product from an unregulated source because of the possibility of contamination and product misbranding. 17 Although more testing is needed, it is imperative for pharmacists to understand what to recommend to patients. Pharmacists should counsel patients on the risks and benefits of treatment. Patients who are are using CBD should be reminded to obtain the product from a reputable manufacturer. 17
Pharmacists need to keep abreast of current information on CBD in order to assist patients who are interested in using it. While most studies are inconclusive, there currently is enough information to effectively guide patients in choosing a treatment. CBD has the most evidence for treatment-resistant seizures; other indications need further study. Patients must be counseled to choose an appropriate product from a reputable source. CBD may be misbranded or contaminated with harmful chemicals. Pharmacists are uniquely positioned to assess the numerous potential drug interactions with CBD. New prescription CBD products are currently being investigated in the U.S.
CBD: A User’s Guide
CBD is seemingly everywhere and in everything, from CBD-infused creams to CBD-infused oils, tinctures, gummies, juices, and lollipops. But does it work, and is it safe? We’ve got your questions covered.
I n case you haven’t heard, CBD is a cure for whatever ails you, from insomnia and inflammation to pandemic angst. Or at least that’s what retailers, supermarkets, mini-marts, beauty stores, and coffee and smoothie shops across America would have you believe. There are CBD-infused creams. CBD-infused oils. CBD-infused tinctures, gummies, juices, lollipops, lattes, nutritional supplements, and even a CBD oil–infused pillow! What’s next, CBD-infused tampons? (Actually, that already exists. Really.)
According to the Brightfield Group, a market research firm, CBD sales were estimated to exceed $4 billion at the end of 2021, and by 2025, the industry’s total market value could reach a whopping $16 billion.
Put that in your pipe and smoke it.
But does CBD work?
That’s a question worthy of a Talmudic scholar, because the CBD world is complicated.
Some believe that it may have an important role to play in certain health outcomes.
Raphael Mechoulam, PhD, a professor of medicinal chemistry at Hebrew University in Jerusalem, Israel, has been studying the health benefits of cannabis and CBD since the early 1960s. Long considered the grandfather of cannabis research, Dr. Mechoulam and his team developed a process for synthesizing certain acids found in the cannabis plant. These acids — otherwise known as cannabidiolic acid (CBDA), and a methylated version of CBDA (CBDA-ME) — have been since studied for a variety of purposes, and might ultimately be used to develop new drugs for everything from arthritis and anxiety to inflammatory bowel disease and psoriasis.
Others believe CBD is unproven and risky.
The U.S. Food and Drug Administration (FDA) continues to investigate its potential harms, noting that while it recognizes the potential opportunity that cannabis-derived compounds (like CBD) can offer, it remains concerned about CBD products being marketed as supplements. (According to the FDA, THC and CBD products do not fit the definition of a dietary supplement.)
“FDA is aware that some companies are marketing products containing cannabis and cannabis-derived compounds in ways that violate the Federal Food, Drug, and Cosmetic Act (FD&C Act), and that may put the health and safety of consumers at risk,” the Agency wrote in its 2021 update, noting that it’s illegal to market CBD by adding it to a food or labeling it as a dietary supplement.
Among a number of problems with CBD, the FDA says, is that it can cause liver damage and diarrhea, it may impact the metabolism of other drugs, and it may cause male reproductive toxicity in humans, as has been found in animal studies.
Still, many consumers continue to believe CBD’s potential benefits. A report (PDF), also from the Brightfield Group, that analyzed 2,400 members of an online community of medical cannabis users found that 59 percent of CBD users say they use it for insomnia and 66 percent for anxiety, while 44 percent have taken it for depression and 49 percent for joint pain and inflammation.
With so much CBD noise out there, we’re feeling a little overwhelmed and confused about CBD. We want to know the real deal. For starters, is CBD the same as cannabis? Should we spend our hard-earned money on the stuff, or is it a scam? Is there any science to back up the claims that CBD is helping people sleep better, feel better, look better, or be an all-around better human? If so, is that in the form of CBD oil, tinctures, lotions, or should we vape it? But wait — isn’t vaping bad for you?
Relax. We’ve got you covered. Herewith, the real scoop on CBD. (Buyer beware: Abbreviations ensue.)
Common Questions & Answers
Endocannabinoids are molecules produced by the body to maintain homeostasis — stability — in response to changes in the environment. The endocannabinoid system interacts with all of the major systems and organs in the body to enable and restore optimal functioning.
The word “cannabinoid” usually refers to a chemical found in the cannabis (marijuana or hemp) plant. “Endo,” in this context, refers to substances produced inside the body. Endocannabinoids are, in effect, the body’s own source of cannabis-like substances.
CBD and THC are plant cannabinoids, which operate much as endocannabinoids do, by attaching to certain receptors on the outsides of cells and altering the behavior of those cells or the bodily systems they are a part of.
Cannabinoids and endocannabinoids can affect pain perception, memory, mood, appetite, and many other bodily systems. The endocannabinoid system regulates the release of other neurotransmitters — that’s how it maintains homeostasis — and helps the body heal from any damage it sustains. Plant cannabinoids can similarly enhance feelings of well-being, but they can have undesirable side effects as well, particularly in young people.
Research suggests that endocannabinoids can be boosted by certain foods, such as those containing essential fatty acids, chocolate, herbs, spices, and teas, as well as by stress-reducing activities.
CBD: The Good, the Bad, and the Confusing
Before we get too much into the, er, weeds, it’s important to understand what CBD is and where it comes from.
Cannabis refers to a group of three varieties of marijuana plants with psychoactive properties: Cannabis sativa, Cannabis indica, and Cannabis ruderalis.
Cannabis contains more than 400 compounds, known as cannabinoids (pronounced keh-NAB-eh-noyd). The most well-known and researched are cannabidiol (CBD), and delta-9-tetrahydrocannabidiol (THC). Other lesser known components — THCA, CBN, CBC, and CBG — play different roles and have different effects in the body. (See our CBD glossary for details.)
The component in cannabis that is linked to its intoxicating effects (in other words, the “high,”) is THC. Conversely, CBD won’t get you high. Depending on your goals, this is either a good or a bad thing.
“Hemp” (which incidentally, is considered part of the CBD family) refers to non-intoxicating varieties that are high fiber or high seed-yielding and often used for rope, clothing, or sails. (Cocktail party fact: “The word ‘canvas’ comes from ‘cannabis,’ as it was made from cannabis fiber varietals,” says Will Kleidon, the CEO of Ojai Energetics in Ojai, California..)
In the United States, the legal definition of hemp is any cannabis plant whose delta-9 THC is below 0.3 percent.
What’s the Endocannabinoid System and How Does It Work?
The endocannabinoid system (ECS) is a biological system first described in the 1990s, and it plays a big role in brain, endocrine, and immune function. Its main role, however, is to maintain homeostasis, the internal biological balancing mechanism of the brain and body.
Two main elements of the system are endocannabinoid receptors, classified as CB1 and CB2. The body makes its own cannabinoids, known as endocannabinoids, that can act upon these receptors. But other varieties of cannabinoids, such as CBD, can interact with them, too.
What Are Cannabinoid Receptors?
Cannabinoid receptors are laced throughout the body, brain, and nerves.
- Cannabinoid 1 (CB1) Receptors Most of these are in the central nervous system, especially neurons (nerve cells) in the brain.
- Cannabinoid 2 (CB2) Receptors These are located mainly on immune cells but are also found in the central nervous system.
Both receptor types are activated by cannabinoids, which can be generated naturally inside the body (known as endocannabinoids) or can be introduced through a form of cannabis.
What’s the ‘Entourage Effect’?
The entourage effect refers to a theory that the whole is more effective than each part — or that the various compounds of the cannabis plant work best synergistically.
“It’s the theory that the cannabinoids, flavonoids, terpenes, and fatty acids all work together like an orchestra, in which all the instruments complement each other so you get the maximum effect of the plant,” says the cannabis researcher Monica Taing, PharmD. “CBD by itself can be a pain reliever, and THC can be a pain reliever by itself, but when combined, they work better for pain relief. That’s the entourage or ensemble effect.”
Now that that’s out of the way, let’s get into the nitty-gritty.
What Are the Legal Implications of Using CBD?
The legality of CBD is confusing.
In 2018, the Agriculture Improvement Act of 2018 (aka that year’s Farm Bill), legalized CBD derived from hemp — with the important caveat that it could only contain 0.3 percent of THC by dry weight, to be grown legally. This type of CBD is legal in 47 U.S. states with some restrictions, but totally illegal in Idaho, South Dakota, and Mississippi. Plants with more than 0.3 percent of THC are considered marijuana, which is legal for recreational use in 19 states, Washington, DC, and Guam.
Despite state laws legalizing the sale of cannabis for recreational or medicinal use, the Drug Enforcement Administration (DEA) (PDF) still classifies it as a Schedule 1 drug: “substances or chemicals [that] are defined as drugs with no currently accepted medical use and a high potential for abuse.” So, while marijuana is illegal on a federal level, states have different laws regarding marijuana and CBD.
Only one cannabis-derived drug product has been FDA approved: cannabidiol sold under the brand name Epidiolex, which contains a purified form of high-dose CBD to treat a rare, hard-to-treat form of epilepsy in children ages 1 and up.
How Do I Find Safe CBD Products? How Do I Know What I’m Getting?
Short answer: You often don’t.
The situation is not unlike that of dietary supplements, except for in the case of supplements, the FDA has defined a very clear set of restrictions — and the Federal Trade Commission, strict reinforcement of health claims. While the FDA has sent warning letters to certain companies selling CBD products, many products slip under the radar. In addition, state and Federal CBD regulations are at odds, so oversight can be difficult. What’s more, every state where medical or recreational marijuana is legal has its own testing rules and regulations, so something that passes muster in Massachusetts might not in California.
People often buy their products online or at the local drugstore or gas station, meaning that they often don’t know what they’re getting.
“Some CBD products don’t contain CBD, but they contain THC and heavy metals, so we need strong regulations,” says Dr. Taing. Indeed, as of May 21, 2022, poison control centers have managed 2,652 cases related to CBD, per the American Association of Poison Control Centers.
Some people have failed drug tests because they’ve unwittingly taken THC that was in a product that was supposed to contain only CBD. A study published in the Journal of the American Medical Association (JAMA) in November 2017 found that 21 percent of CBD products derived from hemp and sold online contained THC, even though THC wasn’t listed on the packaging.
A more recent study in JAMA Psychiatry showed that even a high-quality, high-potency cannabidiol product labeled as carrying as much as tenfold less than the legal limits of THC permissible under law might still result in positive urine drug tests.
Findings from another study, published June 2022 in the Journal of Cannabis Research, showed that of the 80 products evaluated, 37 contained CBD concentrations that were at least 10 percent higher or lower than the concentration listed on the label: 12 products contained less than 90 of what was listed, while 25 products contained more than 110 percent.
Even more worrisome, a study published in January 2019 in Forensic Science International examined nine liquids that were advertised as 100 percent natural CBD extract and found they contained potentially problematic compounds. One contained dextromethorphan, which is used in over-the-counter cough medication and is considered addictive when abused. Four others had a synthetic cannabinoid that can cause, among other things, anxiety, psychosis, and even death.
“As with any other product you would ingest, you have to be smart,” says Jahan Marcu, PhD, the editor in chief of the American Journal of Endocannabinoid Medicine, and the cofounder and chief science officer at the International Research Center on Cannabis and Mental Health.
What’s more, he says, every product should have a certificate of analysis, or COA — a document generated by a laboratory certifying its legitimacy and also listing the ingredients.
The Mayo Clinic uses the following checklist to identify high-quality products, as described in a 2019 issue of Mayo Clinic Proceedings:
- Does it meet the following quality standards? These include Current Good Manufacturing Practices (CGMP) certification from the FDA; European Union (EU), Australian (AUS), or Canadian (CFIA) organic certification; National Science Foundation (NSF) International certification.
- Does the company have an independent adverse event reporting program?
- Is the product certified organic or eco-farmed?
- Have their products been laboratory tested by batch to confirm tetrahydrocannabinol levels below 0.3 percent and no pesticides or heavy metals?
For more information, Project CBD, Certified Kind, Clean Green, and WeedMaps offer information on dispensaries, cannabis products, and brands.
Does It Matter if the CBD Is Organic?
In theory, yes, because without an organic label, there’s a potential for ingesting pesticides and chemical fertilizers. If you have a COA, then you’ll know what’s in the product.
But here’s the rub: Organic products are regulated by the U.S. Department of Agriculture (USDA), which is a federal agency. Since cannabis is considered a Schedule 1 drug, technically, medical cannabis couldn’t be designated as “organic,” unless it’s made from hemp.
In May 2018, Palmetto Grow became the first company to have USDA Organic certification for hemp flower and seed. Since then, other organic growers have joined the market. You can find a list of some of the best organic CBD products from EcoWatch and The Honest Consumer.