CBD Oil and Autoimmune Disorders

CBD is the abbreviation for cannabidiol, which is a cannabinoid that is present in cannabis plants and their extracts. Cannabidiol was first isolated in 1934 (Robson, 2001). Cannabidiol is the main cannabinoid that is not psychoactive in cannabis plants (Buchweitz, Karmaus, Williams, Harkema, & Kaminski, 2008). Like the psychoactive cannabinoid tetrahydrocannabinol (THC), however, CBD does have central nervous system activity in the human body (Tzadok et al., 2016). CBD works as a cannabinoid receptor antagonist to modulate the body’s endogenous cannabinoid receptors by potentiating the transmission of neurochemicals (Tzadok et al., 2016). It also works to regulate other neurotransmitters and receptors in the brain.

A large number of studies have shown that CBD has many beneficial biological effects, including analgesic, anti-convulsant, anti-depressant, anti-diarrheal, anti-dystonia, anti-emetic, anti-inflammatory, anti-microbial, anti-oxidant, anti-proliferative, anti-psychotic, anxiolytic, cardioprotective, and sleep-inducing (reviewed in Wilbur & Glauser, 2015). CBD oil is cannabidiol that is extracted from cannabis plants that are high in the cannabinoid CBD and low in the psychoactive compound THC (Medical Marijuana Inc, 2016). It has non-psychoactive properties and is known to interact with the body through the endocannabinoid system (Wilbur and Glauser, 2015).

Current Practices and Uses of CBD Oil

Most of the conditions for which medicinal cannabis is used involve the cannabinoid CBD. According to the U.S. National Library of Medicine (2017), cannabidiol comprises about 40% of the extracts from cannabis, and is used taken orally for conditions such as anxiety, bipolar disorder, dystonia, multiple sclerosis, Parkinson’s disease, seizures, and schizophrenia (U.S. National Library of Medicine, 2017). Cannabidiol can also be inhaled to assist with smoking cessation.

CBD has received a large amount of attention because of its anti-seizure properties. Several trials have shown that CBD can reduce or eliminate seizures in some individuals. For instance, a recent double-blind, placebo-controlled trial of children and young adults who have drug-resistant seizures from Dravet Syndrome found that a dose of 20 mg per kilogram of body weight per day decreased the median frequency of convulsive seizures from 12.4 per month to 5.9, and this was significant at p=0.1 compared to the placebo (Devinsky et al., 2017).  However, the U.S. National Library of Medicine (2017) cautions that these seizure reduction effects have not been seen in all studies, and further research needs to be carried out.

There is also good evidence, especially from animal studies, that suggests that CBD may be useful in autoimmune disorders such as inflammatory bowel disease or disorders that have an autoimmune component such as multiple sclerosis. A study in laboratory mice found that a standardized extract of cannabis that is high in CBD that was administered after an inflammatory condition was induced was able to mitigate injury and motility in the intestines of the animals (Pagano et al., 2016). CBD has also been found to have anti-inflammatory effects in animal studies of T cell-mediated autoimmune disorders such as collagen-induced arthritis, autoimmune diabetes, and autoimmune hepatitis (Kozela et al., 2016). Studies have also shown that systemically administered CBD can also reduce symptoms in animal models of experimentally induced autoimmune encephalitis that is a model for multiple sclerosis (Kozela et al., 2016).

Kozela et al. (2016) were able to use a mouse model to elucidate the mechanism by which CBD can cause anti-inflammatory effects and have beneficial effects on pathological memory T cells and in autoimmune disorders. They demonstrated that the immune regulatory functions of CBD in activated memory T cells occur in five ways. These are by “suppressing proinflammatory Th17 –related transcription...by promoting T cell exhaustion/tolerance...enhancing IFN-dependent anti-proliferative program...hampering antigen presentation, and... inducing antioxidant milieu resolving inflammation” (Kozela et al., 2016, p. 2). This is significant work because it provides an understanding of the mechanisms by which CBD is able to reduce some of the symptoms and underlying pathology of T-cell autoimmune disorders.

There are many avenues for future research on the ability of CBD oil to mitigate the effects of autoimmune disorders to take. Most of the research to date has been conducted in animal models, and while these give important insights into the ways in which the compound acts in the body, and the mechanisms by which it acts, they do not fully explain how the compound will act in the human body. Also, it will be very important for studies to be conducted for the purposes of ascertainment of appropriate dosages for different groups of people (such as children versus adults), side effects, drug interactions, and effects of the drug on comorbid conditions.

Current Policies/Laws Regarding CBD Oil

According to the group Americans for Safe Access (2017), medicinal marijuana is still not legal in all 50 states, and cannabis and its products are still illegal in terms of federal law. The Controlled Substances Act (21 U.S.C. § 811) does not recognize any difference between medicinal and recreational use of cannabis products, and it can be treated like any other controlled substance (Americans for Safe Access, 2017). This means that federal cannabis laws must be taken seriously, and individuals who are found guilty of possession, cultivation, or distribution of certain quantities of the substance may be punished and may be punished harshly.

That being said, it is the case that in 2013, the Department of Justice issued a memo that indicated that it is not a priority for them to prosecute any state cases of legal medical marijuana (Americans for Safe Access, 2017). There are strict guidelines, however, that include preventing the sale of cannabis and its products to minors, preventing the diversion of cannabis from states in which it is legal to other states, and preventing the use or even possession of cannabis on federal property. These restrictions could pose serious limitations on individuals seeking to use cannabis and/or cannabis products for medicinal purposes.

CBD Oil and Advanced Practice Nurses in the Community Setting

There is still a lack of consensus in the medical community regarding the use of cannabis and cannabis extracts such as CBD for the treatment of various health conditions (Mathern, Beninsig, & Nehlig, 2015). This is likely because of the issues with legality at the federal level, and because the research is still in its infancy in regard to randomized controlled trials in humans. The American Nurses Association  (ANA, 2016) issued a position statement that indicates their support for “the review and reclassification of marijuana’s status from a federal Schedule I controlled substances to facilitate urgently needed clinical research to inform patients and providers on the efficacy of marijuana and related cannabinoids” (para. 1). The ANA supports the establishment of evidence-based practice standards for the use of cannabis and cannabinoids, and protection from criminal or civil penalties for patients using therapeutic cannabis/cannabinoids. Although advanced practice nurses cannot provide cannabis to their patients, they can, with the sanction of the ANA, support them in the use of cannabis and cannabinoids for health issues. Nurses can also work to become educated and in turn educate their patients about the known benefits and detriments of the use of cannabis/cannabinoids for specific conditions.

Cost and Availability of CBD Oil

According to an article in the Washington Post (Kohn, 2016), the price and availability of CBD and CBD oil can vary greatly. Treatment with CBD varies with the dosage and the dispensary where it is obtained and runs anywhere from $100 per month to over $1000 per month. What is more, although medicinal cannabis and its extracts are now legal in many states around the country (Kohn, 2016; Wilbur and Glauser, 2015) it is not covered by any insurance plan, and patients must, therefore, pay for it out of pocket. This can make the cost of treatment prohibitive for many families.

Variations and Dosage of CBD Oil

One of the current issues with medicinal marijuana products such as CBD oil is that there is not any currently standardized treatment regimen (Kohn, 2016). Most of the products are not tested by any reputable company and are certainly not approved by the Food and Drug Administration (FDA). Some dispensaries and suppliers are known to test for the levels of cannabinoids such as CBD and THC, the latter of which would not be good for children or those who are not seeking a high, but many do not perform any tests, and thus the actual amount of the cannabinoid compounds that one is ingesting remains unknown (Kohn, 2016).

Information from the U.S. National Library of Medicine (2017) indicates that CBD may be safe when taken orally or sprayed sublingually by adults. Doses up to 300 mg per day of cannabidiol has been found to be safe when taken for no more than 6 month time periods. Individuals have also taken dosages of 1200 to 1500 mg per day orally for no more than 4 weeks. Under the tongue sprays of CBD have been reported to be safely used in doses of 2.5 mg for no more than 2 weeks (U.S. National Library of Medicine, 2017). However, more research is needed to elucidate the exact dosages for varying conditions, varying age groups, and other parameters. CBD has the reported side effects of drowsiness, dry mouth, hypotension and lightheadedness (U.S. National Library of Medicine, 2017).

Current and Potential Barriers to Implementing Use of CBD Oil

As discussed above, an important barrier to implementing the use of CBD oil products for autoimmune or other disorders is that there is no standardization of the compounds. Additionally, because there has been a relative lack of scientific testing of these compounds, dosing and timing of dosages are largely unknown. These are important areas for research to be conducted, but such does not happen overnight, and it cannot be expected that an understanding of dosing, timing, and standardization of cannabis products such as CBD oil will occur anytime within the next few years.

There are, as well, additional important areas of research that need to be undertaken in humans. Although there are increasing numbers of animal studies, the research is still sparse concerning the types of side effects that some people may experience from various dosages of cannabinoid extracts such as CBD. As well, research needs to be performed on the types of interactions that cannabinoids might have with other medications that a patient could be taking concurrently. Along those lines, it will be important to discover the ways in which other co-morbid conditions that a patient may have could be affected by cannabinoids. And it is of course of great importance to know how different cannabinoids and dosages of such will affect individuals of different ages, especially children and the elderly.

Another barrier to using CBD oil is the cost. As mentioned above, this is not something that most insurance plans cover, and it is unknown if and when any will. This likely will only come about with growing legality of the drugs at the state and federal levels, and with adequate research to indicate the safety profiles of the compounds and the possible side effects and other potential adverse events that could occur. Cost, therefore, will be prohibitive for many patients, especially those who are below the poverty line or who are living on fixed incomes, such as many seniors.

Finally, there are the legalities of using CBD oil to consider. Although it is legal in 44 states to use medicinal cannabis and products from it, it is not legal at the federal level, and there are strict guidelines that have been issued to the states by the federal government. These laws can be very prohibitive for individuals seeking to use medicinal marijuana or its products, including CBD oil. In particular, there is a restriction against allowing minors to have medicinal marijuana, and this could limit its use for pediatric illnesses. In all, then, there are still many barriers in the way of the use of cannabis and its products, including CBD oil, for regular medicinal purposes.

References

Americans for Safe Access. (2017). Legal information by state & federal law. Retrieved from http://www.safeaccessnow.org/state_and_federal_law

ANA. (2016). Therapeutic use of marijuana and related cannabinoids. Retrieved from http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ANAPositionStatements/Position-Statements-Alphabetically/Therapeutic-Use-of-Marijuana-and-Related-Cannabinoids.pdf

Buchweitz, J. P., Karmaus, P. W. F., Williams, K. J., Harkema, J. R., & Kaminski, N. E. (2008). Targeted deletion of cannabinoid receptors CB1 and CB2 produced enhanced inflammatory responses to influenza A/PR/8/34 in the absence and presence of Delta9-tetrahydrocannabinol. Journal of Leukocyte Biology, 83(3), 785–96. http://doi.org/10.1189/jlb.0907618

Devinsky, O., Cross, H., Laux, L., Marsh, E., Miller, I., Nabbout, R., … Wright, S. (2017). Trial of cannabidiol for drug-resistant seizures in the Dravet Syndrome. New England Journal of Medicine, 376, 2011–2020.

Kohn, D. (2016). A powerful new form of medical marijuana, without the high. Retrieved from https://www.washingtonpost.com/national/health-science/a-powerful-new-form-of-medical-marijuana-without-the-high/2016/12/29/81bbf7c0-b5b2-11e6-b8df-600bd9d38a02_story.html?utm_term=.cd1ac63bc984

Kozela, E., Juknat, A., Gao, F., Kaushansky, N., Coppola, G., & Vogel, Z. (2016). Pathways and gene networks mediating the regulatory effects of cannabidiol, a nonpsychoactive cannabinoid, in autoimmune T cells. Journal of Neuroinflammation, 13(1), 136. http://doi.org/10.1186/s12974-016-0603-x

Mathern, G. W., Beninsig, L., & Nehlig, A. (2015). Fewer specialists support using medical marijuana and CBD in treating epilepsy patients compared with other medical professionals and patients: Result of Epilepsia ’s survey. Epilepsia, 56(1), 1–6. http://doi.org/10.1111/epi.12843

Medical Marijuana Inc. (2016). What is CBD (cannabidiol) hemp oil? Retrieved from http://www.medicalmarijuanainc.com/what-is-cbd-hemp-oil/

Pagano, E., Capasso, R., Piscitelli, F., Romano, B., Parisi, O. A., Finizio, S., … Borrelli, F. (2016). An Orally Active Cannabis Extract with High Content in Cannabidiol attenuates Chemically-induced Intestinal Inflammation and Hypermotility in the Mouse. Frontiers in Pharmacology, 7, 341. http://doi.org/10.3389/fphar.2016.00341

Robson, P. (2001). Therapeutic aspects of cannabis and cannabinoids. British Journal of Psychiatry, 178(2), 107–115.

Tzadok, M., Uliel-Siboni, S., Linder, I., Kramer, U., Epstein, O., Menascu, S., … Ben-Zeev, B. (2016). CBD-enriched medical cannabis for intractable pediatric epilepsy. Seizure, 35, 41–44. http://doi.org/10.1016/j.seizure.2016.01.004

U.S. National Library of Medicine. (2017). Cannabidiol. Retrieved from https://medlineplus.gov/druginfo/natural/1439.html

Wilbur, A. K., & Glauser, L. (2015). Medical Marijuana Desk Reference. Henderson, NV: Signal Bay Research, Inc.