Access to cannabidiol without a prescription: A cross-country comparison and analysis

Use and perceptions of Cannabidiol among individuals in treatment for opioid use disorder

BACKGROUND

Cannabidiol (CBD) is a widely available cannabis product with many claims as to potential health benefits including alleviating symptoms related to opioid use disorder (OUD). However, little is known as to how individuals with OUD perceive CBD, to what extent they may already be using CBD, and for what purposes.

METHODS

A survey was conducted among individuals receiving treatment for OUD at the Addiction Institute of Mount Sinai in New York City from July 2021 to August 2023. The survey consisted of demographic questions, questions about opioid use, CBD use, and perceptions regarding CBD. Statistical analysis using ordinal logistic regression was employed to compare perceptions between CBD users and non-users while adjusting for age and race.

RESULTS

Among 587 respondents, 550 completed the survey. Among all survey completers, 129 (23%) reported a history of using CBD for a variety of reasons including: anxiety (81, 62.8%), pain (65, 50.4%), sleep (63, 48.8%), depression (62, 48.1%), recreational purposes (32, 24.8%), or for other reasons (8, 6.2%). Of note, 22 (17.1%) respondents reported using CBD to control their addiction and 54 (41.9%) reported using CBD to ease opioid withdrawal symptoms. CBD users demonstrated more positive perceptions regarding its legality (β = 0.673, OR = 1.960, 95% CI [1.211, 3.176], p = .006), social acceptance (β = 0.718, OR = 2.051, 95% CI [1.257, 3.341], p = .004), and therapeutic potential compared to non-users. CBD users also had a more positive view of its potential future role in managing addiction (β = 0.613, OR = 1.846, 95% CI [1.181, 2.887], p = .007).

CONCLUSIONS

This study highlights a significant association between CBD usage and progressive views regarding CBD among individuals with OUD, suggesting a growing interest in CBD as a potential adjunctive therapy for individuals in substance use treatment. Some patients are already using CBD for anxiety, pain, sleep, depression, or as a harm reduction intervention to control their addiction or for opioid withdrawal symptoms. These findings underscore the importance of integrating patient perspectives into future research and treatment strategies involving CBD in the context of OUD.

From bench to bedside: the application of cannabidiol in glioma

Glioma is the most common malignant tumor in central nervous system, with significant health burdens to patients. Due to the intrinsic characteristics of glioma and the lack of breakthroughs in treatment modalities, the prognosis for most patients remains poor. This results in a heavy psychological and financial load worldwide. In recent years, cannabidiol (CBD) has garnered widespread attention and research due to its anti-tumoral, anti-inflammatory, and neuroprotective properties. This review comprehensively summarizes the preclinical and clinical research on the use of CBD in glioma therapy, as well as the current status of nanomedicine formulations of CBD, and discusses the potential and challenges of CBD in glioma therapy in the future.

Spray freeze dried cannabidiol with dipalmitoylphosphatidylcholine (DPPC) for inhalation and solubility enhancement

Pulmonary delivery is an efficient route of administration to deliver cannabidiol (CBD) due to the high bioavailability and fast onset of action. The major formulation challenge is the poor aqueous solubility of CBD. This study aimed to produce inhalable CBD powders with enhanced solubility and characterise their solid-state properties. CBD was spray freeze dried with mannitol or trehalose dihydrate with and without dipalmitoylphosphatidylcholine (DPPC). All four powders had acceptable yields at > 70 % with porous and spherical particles. The two crystalline mannitol powders contained less residual solvent than both amorphous trehalose ones. The addition of DPPC did not affect the crystallinity and residual solvent level of the powders. Instead, DPPC made the particles more porous, decreased the particle size from 19-23 µm to 11-13 µm, and increased CBD solubility from 0.36 µg/mL to over 2 µg/mL. The two DPPC powders were dispersed from a low resistance RS01 inhaler, showing acceptable aerosol performance with emitted fractions at 91-93 % and fine particle fractions < 5 µm at 34-43 %. These formulations can be used as a platform to deliver CBD and other cannabinoids by inhalation.

Therapeutic potential of cannabidiol (CBD) in anxiety disorders: A systematic review and meta-analysis

Cannabidiol (CBD), as one of the phytocannabinoids, has a wide range of therapeutic properties for various neuropsychiatric disorders due to central nervous system effects. These therapeutic properties demonstrated by preclinical and clinical studies encompass more than just anticonvulsant, anti-arthritic, analgesic, anti-inflammatory, antioxidant, antitumor, antiemetic, antipsychotic and neuroprotective effects. It has been hypothesized that CBD holds potential in the treatment of various neuropsychiatric and anxiety disorders. Thus, PRISMA was used as a guide for our systematic review. Eight of the 1550 articles screened in June 2023 were eligible for meta-analysis. Based on the 316 participants included in these eight articles, this meta-analysis revealed a substantial significant impact of CBD on anxiety with a considerable effect size (Hedges' g = -0.92, 95% CI -1.80 to -0.04). In addition, this meta-analysis focuses on the efficacy of CBD in treating anxiety disorders such as generalized anxiety disorder (GAD), social anxiety disorder (SAD), and post-traumatic stress disorder (PTSD). However, caution should be exercised in interpreting our findings due to the limited size of the clinical sample, and additional trials ought to be carried out if deemed necessary.

Comprehensive Insight into Cutaneous Application of Hemp

Known for its natural bio-compounds and therapeutic properties, hemp is being utilized in the development of skin products. These products offer a wide range of applications and benefits in the fields of natural bio-compounds, pharmaceutical technology, topical delivery systems, and cosmeceuticals. This manuscript deals with hemp actives, such as cannabinoids, terpenes, and flavonoids, and their diverse biological properties relative to topical application, including anti-inflammatory, antimicrobial, and antioxidant effects. Also, the paper reviews strategies to overcome poor penetration of hemp actives, as well as the integration of hemp actives in cosmeceuticals that provide natural and sustainable alternatives to traditional skincare products offering a range of benefits, including anti-aging, moisturizing, and soothing properties. The review aims to provide a comprehensive understanding of the development and manufacturing processes of skin products containing hemp actives. By delving into the science behind hemp-based products, the paper provides valuable insights into the potential of hemp as a versatile ingredient in the pharmaceutical and cosmetic industries. The utilization of hemp in these innovative products not only offers therapeutic benefits but also promotes natural and sustainable approaches to skincare.

The Effect of Cannabidiol on Subjective Responses to Endurance Exercise: A Randomised Controlled Trial

BACKGROUND

Exercise is known to improve health. However, it can be unpleasant, often inducing negative feelings, or 'affect'. Cannabidiol (CBD), a non-intoxicating constituent of the cannabis plant, has been reported to enhance the subjective experience of exercise; specifically, in trained individuals performing fixed-intensity endurance activity. Here, we investigated the effects of CBD on subjective responses to exercise under more ecologically valid conditions; namely, in recreationally active individuals performing self-paced endurance activity.

METHODS

A randomised, double-blind, placebo-controlled, crossover trial was conducted at Griffith University between July 17 and August 28, 2023. Griffith University students studying sports nutrition were invited to take part, with eligible volunteers ≥ 18 years of age and able to perform endurance exercise. Participants ingested placebo or 150 mg CBD in two soft-gel capsules 90 min before completing a self-paced 25-lap (10 km) run around an outdoor athletics track (400 m, synthetic). The primary outcomes were affective valence during exercise, assessed on completion of laps 6, 12, 18 and 24 using the 'Feelings Scale', and positive and negative affect, assessed at baseline, pre-run and post-run using the 'Positive and Negative Affect Schedule'. Exercise enjoyment, motivation and self-efficacy, the core features of the 'runner's high' (i.e., euphoria, pain, anxiety, sedation), perceived exertion and run time were also assessed.

RESULTS

Fifty-two participants were randomised and 51 were included in the final sample (n = 22 female; 22 [21-25] years). Exercise induced negative affect (i.e., at the time of undertaking) and increased pain. CBD did not counteract either response. In fact, CBD had no significant effects on any of the outcomes measured. In contrast, exercise, once completed, increased positive affect, and decreased negative affect and anxiety.

CONCLUSIONS

CBD (150 mg, oral) does not appear to enhance the subjective experience of self-paced endurance exercise in recreationally active individuals. Nor, however, does it appear to compromise it. These findings suggest that CBD use is safe under exercise conditions and unlikely to impede physical activity participation. Our study also reaffirms the powerful mood-enhancing effects of exercise.

TRIAL REGISTRATION

Registered with the Australian New Zealand Clinical Trials Registry ( www.anzctr.org.au ) on May 31, 2023 (Trial ID: ACTRN12623000593639).

Interactions between antiepileptic drugs and direct oral anticoagulants for primary and secondary stroke prevention

INTRODUCTION

Direct oral anticoagulants (DOAC) are the guideline-recommended therapy for prevention of stroke in atrial fibrillation (AF) and venous thromboembolism. Since approximately 10% of patients using antiepileptic drugs (AED) also receive DOAC, aim of this review is to summarize data about drug-drug interactions (DDI) of DOAC with AED by using data from PubMed until December 2023.

AREAS COVERED

Of 49 AED, only 16 have been investigated regarding DDI with DOAC by case reports or observational studies. No increased risk for stroke was reported only for topiramate, zonisamide, pregabalin, and gabapentin, whereas for the remaining 12 AED conflicting results regarding the risk for stroke and bleeding were found. Further 16 AED have the potential for pharmacodynamic or pharmacokinetic DDI, but no data regarding DOAC are available. For the remaining 17 AED it is unknown if they have DDI with DOAC.

EXPERT OPINION

Knowledge about pharmacokinetic and pharmacodynamic DDI of AED and DOAC is limited and frequently restricted to in vitro and in vivo findings. Since no data about DDI with DOAC are available for 67% of AED and an increasing number of patients have a combined medication of DOAC and AED, there is an urgent need for research on this topic.

Effects of cannabidiol on psychosocial stress, situational anxiety and nausea in a virtual reality environment: a protocol for a single-centre randomised clinical trial

INTRODUCTION

The non-intoxicating plant-derived cannabinoid, cannabidiol (CBD), has demonstrated therapeutic potential in a number of clinical conditions. Most successful clinical trials have used relatively high (≥300 mg) oral doses of CBD. Relatively few studies have investigated the efficacy of lower (<300 mg) oral doses, typical of those available in over-the-counter CBD products.

METHODS

We present a protocol for a randomised, double-blind, placebo-controlled, parallel-group clinical trial investigating the effects of a low oral dose (150 mg) of CBD on acute psychosocial stress, situational anxiety, motion sickness and cybersickness in healthy individuals. Participants (n=74) will receive 150 mg of CBD or a matched placebo 90 min before completing three virtual reality (VR) challenges (tasks) designed to induce transient stress and motion sickness: (a) a 15 min 'Public Speaking' task; (b) a 5 min 'Walk the Plank' task (above a sheer drop); and (c) a 5 min 'Rollercoaster Ride' task. The primary outcomes will be self-reported stress and nausea measured on 100 mm Visual Analogue Scales. Secondary outcomes will include salivary cortisol concentrations, skin conductance, heart rate and vomiting episodes (if any). Statistical analyses will test the hypothesis that CBD reduces nausea and attenuates subjective, endocrine and physiological responses to stress compared with placebo. This study will indicate whether low-dose oral CBD has positive effects in reducing acute psychosocial stress, situational anxiety, motion sickness and cybersickness.

ETHICS AND DISSEMINATION

The University of Sydney Human Research Ethics Committee has granted approval (2023/307, version 1.6, 16 February 2024). Study findings will be disseminated in a peer-reviewed journal and at academic conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12623000872639).

Cannabidiol's impact on drug-metabolization

IMPORTANCE

Products containing cannabidiol(CBD) are easily accessible. CBD is reported to inhibit the drug-metabolizing proteins(DMP) Cytochrome P450(CYP)3A4/5, CYP2C9, CYP2B6, CYP2D6, CYP2E1, CYP1A2, CYP2C19, carboxylesterase 1(CES1), uridine 5'diphospho-glucoronosyltransferase(UGT)1A9, UGT2B7, P-glycoprotein(P-gp) and Breast Cancer Resistance Protein(BCRP). The relevance of CBD-drug interactions is largely unknown. Aim of the study was to identify drugs, potentially interacting with orally ingested CBD, to assess whether CBD-drug interactions have been reported, and if substrates of DMP are frequently prescribed drugs.

OBSERVATIONS

Identified were 403 drugs as substrates of DMP. CBD-drug interactions were reported for 53/403 substrates in humans (n = 25), in vivo (n = 13) or in vitro (n = 15). In 31/53 substrates, CBD induced an increase, in 1/53 a decrease, in 4/53 no change in the substrate level. For 5/53 substrates, the results were controversial, and in 12/53 no substrate levels were reported. Among the 30 most frequently prescribed drugs in Germany were 67% substrates of DMP and among the 50 most frequently prescribed drugs in the USA 68%.

RELEVANCE AND CONCLUSIONS

There is an urgent need for pharmacologic studies on CBD-drug interactions. Patients should be educated on the potential risk and awareness should be increased among physicians. Regulatory authorities should become aware of the problem and start an initiative on an international level to increase the safety of CBD.

Cannabidiol Knowledge, Perceptions, and Use Among Young Adults in 6 U.S. Metropolitan Areas

Background: Cannabidiol (CBD) has gained popularity in the United States, particularly among certain populations, including young adults. Thus, we examined (1) CBD product knowledge, perceptions, use, and use intentions among young adults and (2) correlates of use and use intentions. Methods: We analyzed data from a Fall 2020 survey regarding tobacco and other substance use among 2464 young adults in 6 U.S. cities (Mage=24.67; 57.4% female; 28.7% racial/ethnic minority). We used multinomial regression to identify correlates of use status (i.e., former [ever but no past 6 months] use vs. current [past 6 months] and never use, respectively), and linear regression to examine use intentions among never users. Results: Around 51.4% reported ever use, and 32.0% reported current use. On average, participants perceived CBD as safe and effective for addressing pain, anxiety, and sleep (also prominent use motives: ∼40% to 60%, respectively). Use intentions were relatively high, particularly for edibles and topicals (also the most common use modes). Roughly one-fourth mistakenly believed that CBD products were required to be approved by U.S. Food and Drug Administration (24.9%), tested/proven safe (28.8%), and proven effective to be marketed for pain, anxiety, sleep, and so on. (27.2%). Compared to former users, never users perceived greater CBD-related risk (p<0.001), less social acceptability (p<0.001), and greater difficulty accessing CBD (p=0.004); current users perceived more health benefits (p<0.001). Among never users, greater use intentions were associated with greater perceived social acceptability (p<0.001), health benefits (p<0.001), and difficulty accessing CBD (p=0.005). Conclusions: Given misperceptions about CBD, surveillance of young adults' knowledge, perceptions, and use of CBD is critical as its market expands.

Health, safety, and socioeconomic impacts of cannabis liberalization laws: An evidence and gap map

Background

Globally, cannabis laws and regulations are rapidly changing. Countries are increasingly permitting access to cannabis under various decriminalization, medicalization, and legalization laws. With strong economic, public health, and social justice incentives driving these domestic cannabis policy reforms, liberalization trends are bound to continue. However, despite a large and growing body of interdisciplinary research addressing the policy-relevant health, safety, and socioeconomic consequences of cannabis liberalization, there is a lack of robust primary and systematic research that comprehensively investigates the consequences of these reforms.

Objectives

This evidence and gap map (EGM) summarizes the empirical evidence on cannabis liberalization policies. Primary objectives were to develop a conceptual framework linking cannabis liberalization policies to relevant outcomes, descriptively summarize the empirical evidence, and identify areas of evidence concentration and gaps.

Search Methods

We comprehensively searched for eligible English-language empirical studies published across 23 academic databases and 11 gray literature sources through August 2020. Additions to the pool of potentially eligible studies from supplemental sources were made through November 2020.

Selection Criteria

The conceptual framework for this EGM draws upon a legal epidemiological perspective highlighting the causal effects of law and policy on population-level outcomes. Eligible interventions include policies that create or expand access to a legal or decriminalized supply of cannabis: comprehensive medical cannabis laws (MCLs), limited medical cannabidiol laws (CBDLs), recreational cannabis laws (RCLs), industrial hemp laws (IHLs), and decriminalization of cultivations laws (DCLs). Eligible outcomes include intermediate responses (i.e., attitudes/behaviors and markets/environments) and longer-term consequences (health, safety, and socioeconomic outcomes) of these laws.

Data Collection and Analysis

Both dual screening and dual data extraction were performed with third person deconfliction. Primary studies were appraised using the Maryland Scientific Methods Scale and systematic reviews were assessed using AMSTAR 2.

Main Results

The EGM includes 447 studies, comprising 438 primary studies and nine systematic reviews. Most research derives from the United States, with little research from other countries. By far, most cannabis liberalization research focuses on the effects of MCLs and RCLs. Studies targeting other laws-including CBDLs, IHLs, and DCLs-are relatively rare. Of the 113 distinct outcomes we documented, cannabis use was the single most frequently investigated. More than half these outcomes were addressed by three or fewer studies, highlighting substantial evidence gaps in the literature. The systematic evidence base is relatively small, comprising just seven completed reviews on cannabis use (3), opioid-related harms (3), and alcohol-related outcomes (1). Moreover, we have limited confidence in the reviews, as five were appraised as minimal quality and two as low quality.

Authors’ Conclusions

More primary and systematic research is needed to better understand the effects of cannabis liberalization laws on longer-term-and arguably more salient-health, safety, and socioeconomic outcomes. Since most research concerns MCLs and RCLs, there is a critical need for research on the societal impacts of industrial hemp production, medical CBD products, and decriminalized cannabis cultivation. Future research should also prioritize understanding the heterogeneous effects of these laws given differences in specific provisions and implementation across jurisdictions.

Cannabidiol Marketing Strategies in the United States: An Analysis of Three Prominent Companies

Introduction: The popularity and market for cannabidiol (CBD) products have expanded. Materials and Methods: Using Numerator advertising data from 2017 to 2021 regarding three popular CBD companies in the United States (Charlotte's Web, Green Roads, Medterra), we examined (1) general advertising characteristics (e.g., media channel, year); (2) ad content (i.e., themes of headlines and imagery); (3) themes of prominent sources (i.e., specific websites, magazines, etc.); and (4) ad expenditures. Results: Across companies during the study timeframe, there were 475 unique ads (i.e., unique content), 4767 ad occurrences, and $1,471,944 total expenditures. Charlotte's Web accounted for the greatest proportion of unique ads, ad occurrences, and expenditures (53.3%, 62.8%, and 70.3%, respectively), followed by Medterra (40.4%, 33.9%, and 28.5%) and Green Roads (6.3%, 3.3%, and 1.2%). The largest proportion of occurrences and expenditures were via online display (83.5%, 54.8%), followed by mobile (15.9%, 24.8%) and print (0.4%, 20.1%). Per ad occurrences and expenditures, ads prominently featured headline themes focused on brand/trust/quality (27.5%, 18.3%, respectively), wellness (17.5%, 17.7%), pain/sport (9.9%, 20.0%), and promotions (13.2%, 11.6%), in addition to visual themes of the product itself (74.3%, 78.5%) or with women (5.3%, 10.0%). The most prominent source themes were focused on health/wellness (21.0% of ad occurrences, 18.1% of expenditures), followed by other websites and search engines (18.3%, 11.2%), news/weather (12.9%, 21.3%), and entertainment/lifestyle/culture (12.6%, 28.0%). Despite some distinctions between companies, ad and source themes were similar. Conclusions: Regulatory efforts must be informed by ongoing surveillance of CBD marketing and how specific consumer subgroups are impacted by marketing exposure.

Effect of vaporizing cannabis rich in cannabidiol on cannabinoid levels in blood and on driving ability - a randomized clinical trial

The aim of this prospective, placebo-controlled, double-blind, randomized, cross-over study was to determine cannabinoid levels in blood and driving-related ability after single (S1) and repetitive (S2) vaporization of cannabis rich in cannabidiol (CBD) containing < 1% Δ9-etrahydrocannabinol (THC). Healthy adult volunteers (Nsingle = 27, Nrepetitive = 20) with experience in smoking vapor-inhaled two low-THC/CBD-rich cannabis products both with < 1% THC (product 1: 38 mg CBD, 1.8 mg THC; product 2: 39 mg CBD, 0.6 mg THC) and placebo. Main outcomes were THC- and CBD-levels in whole blood and overall assessment of driving-related ability by computerized tests. Among 74 participants included, 27 (mean age ± SD, 28.9 ± 12.5 years) completed S1, and 20 (25.2 ± 4.0) completed S2. Peak concentrations and duration of detectability depended on the THC-content of the product. After single consumption THC dropped below 1.5 µg/L after 1.5 h, but was detected in some participants up to 5 h. Pairwise comparison of driving-related ability revealed no significant differences between low-THC/CBD-rich products (P1, P2) and placebo. Detection of THC after consumption of low-THC/CBD-rich cannabis might have legal consequences for drivers. Regarding overall driving-related ability, no significant differences were observed between the interventional products. This trial was registered with the German Clinical Trials Register (DRKS00018836) on 25.10.2019 and with the Coordination Office for Human Research (kofam) which is operated by the Federal Office of Public Health (FOPH) (SNCTP000003294).

A cross-sectional survey exploring the knowledge, experiences and attitudes of Australian pharmacists toward medicinal cannabis

BACKGROUND

Australian pharmacists currently dispense a wide range of prescription-only cannabis-based medicines. Recent regulatory changes will expand the role of pharmacists, allowing certain low-dose cannabidiol products to be supplied without a prescription in pharmacies. This harmonises Australia with many other countries where cannabidiol products are readily available to consumers.

AIM

To examine Australian pharmacists' experience, knowledge and attitudes towards medicinal cannabis and their preparedness to supply over-the-counter low-dose cannabidiol products.

METHOD

We conducted a cross-sectional study using a 51-item on-line questionnaire that was informed by previous surveys of health professionals and assessed for face validity. Australian pharmacists were recruited to complete the survey between May and December 2021, primarily through professional pharmacy organisations. Pharmacists were included in the final dataset if they completed the demographic characteristics section and at least one additional section of the questionnaire. Data were analysed using descriptive and relational statistical tests.

RESULTS

There were 272 attempts to complete this survey and 217 responses included in the final dataset. Over half of the respondents (60.0%, 130/217) had dispensed at least one medicinal cannabis prescription during their career and 58.5% (127/217) had received at least one medicinal cannabis enquiry in the last fortnight. Only around half (53.9%, 117/217) felt comfortable supplying medicinal cannabis products and fewer (39.3%, 79/201) were confident discussing cannabis-related enquiries. More than half of the respondents (58.7%, 118/201) supported the provision of low-dose cannabidiol products through pharmacies. Two-thirds (67.8%, 80/118) of respondents achieved relatively low scores (< 60%) in the knowledge component of the survey. Most respondents (94.2%, 178/189) endorsed a need for further training in this area.

CONCLUSION

Australian pharmacists tended to support medicinal cannabis availability and improved access to low-dose cannabidiol products via pharmacies. However, results highlight a need for improved training and education of pharmacists around cannabis-based medicines.

High-CBD Cannabis Vapor Attenuates Opioid Reward and Partially Modulates Nociception in Female Rats

Chronic pain patients report analgesic effects when using cannabidiol (CBD), a phytocannabinoid found in whole-plant cannabis extract (WPE). Several studies suggest that cannabis-derived products may serve as an analgesic adjunct or alternative to opioids, and importantly, CBD may also attenuate the abuse potential of opioids. Vaping is a popular route of administration among people who use cannabis, however both the therapeutic and hazardous effects of vaping are poorly characterized. Despite the fact that chronic pain is more prevalent in women, the ability of inhaled high-CBD WPE to relieve pain and reduce opioid reward has not been studied in females. Here, we present a comprehensive analysis of high-CBD WPE vapor inhalation in female rats. We found that WPE was modestly efficacious in reversing neuropathy-induced cold allodynia in rats with spared nerve injury (SNI). Chronic exposure to WPE did not affect lung cytoarchitecture or estrous cycle, and it did not induce cognitive impairment, social withdrawal or anxiolytic effects. WPE inhalation prevented morphine-induced conditioned place preference and reinstatement. Similarly, WPE exposure reduced fentanyl self-administration in rats with and without neuropathic pain. We also found that WPE vapor lacks of reinforcing effects compared to the standard excipient used in most vapor administration research. Combined, these results suggest that although high-CBD vapor has modest analgesic effects, it has a robust safety profile, no abuse potential, and it significantly reduces opioid reward in females. Clinical studies examining high-CBD WPE as an adjunct treatment during opioid use disorder are highly warranted.

How long does a single oral dose of cannabidiol persist in plasma? Findings from three clinical trials

A growing number of clinical trials (CTs) are investigating the therapeutic potential of cannabidiol (CBD), a non-intoxicating phytocannabinoid found in Cannabis sativa. These CTs often use crossover experimental designs requiring 'washout' (clearance) periods. However, the length of time CBD persists in plasma (its 'window of detection') is unclear and could be significant. Indeed, the structurally related phytocannabinoid, Δ⁹ -tetrahydrocannabinol (THC), has a long window of detection in plasma. We investigated the extent to which CBD and its major metabolites persist in plasma. Data from three CTs that measured plasma cannabinoid concentrations ≥7 days after administering a single oral dose of CBD were pooled. The CBD doses were as follows: CT #1: 300 mg; CT #2: 200 mg (and 10 mg THC); and CT #3: 15, 300 and 1500 mg (one per treatment session). Thirty-two participants were included in the analysis, 17 of whom (from CT #3) provided repeated measures. Overall, 0% (15 mg), 60% (200 mg), 28% (300 mg) and 100% (1500 mg) of participants had detectable concentrations (i.e., >0.25 ng·ml^-1 ) of CBD in plasma ≥7 days post-treatment (some, several weeks post-treatment). A zero-inflated negative binomial mixed-effects regression analysis (R² _m  = 0.44; R² _c  = 0.73) predicted that, on average, a 13 day washout period would reduce plasma CBD concentrations to 'zero' (i.e., <0.25 ng·ml^-1 ) if a single oral dose of 300 mg was consumed. Higher doses require longer washout periods; concomitant medications may also affect clearance. In conclusion, CBD has a long window of detection in plasma. Crossover studies involving CBD should, therefore, be conducted with caution, particularly when higher doses and/or chronic dosing regimens are used.

Using a global diversity panel of Cannabis sativa L. to develop a near InfraRed-based chemometric application for cannabinoid quantification

C. sativa has gained renewed interest as a cash crop for food, fibre and medicinal markets. Irrespective of the final product, rigorous quantitative testing for cannabinoids, the regulated biologically active constituents of C. sativa, is a legal prerequisite across the supply chains. Currently, the medicinal cannabis and industrial hemp industries depend on costly chromatographic analysis for cannabinoid quantification, limiting production, research and development. Combined with chemometrics, Near-InfraRed spectroscopy (NIRS) has potential as a rapid, accurate and economical alternative method for cannabinoid analysis. Using chromatographic data on 12 therapeutically relevant cannabinoids together with spectral output from a diffuse reflectance NIRS device, predictive chemometric models were built for major and minor cannabinoids using dried, homogenised C. sativa inflorescences from a diverse panel of 84 accessions. Coefficients of determination (r²) of the validation models for 10 of the 12 cannabinoids ranged from 0.8 to 0.95, with models for major cannabinoids showing best performance. NIRS was able to discriminate between neutral and acidic forms of cannabinoids as well as between C₃-alkyl and C₅-alkyl cannabinoids. The results show that NIRS, when used in conjunction with chemometrics, is a promising method to quantify cannabinoids in raw materials with good predictive results.

Comparison of the Users' Attitudes Toward Cannabidiol on Social Media Platforms: Topic Modeling Study

BACKGROUND

As one of the major constituents of the cannabis sativa plant, cannabidiol (CBD) is approved for use in medical treatment and cosmetics because of its potential health benefits. With the rapid growth of the CBD market, customers purchase these products, and relevant discussions are becoming more active on social media.

OBJECTIVE

In this study, we aimed to understand the users' attitudes toward CBD products in various countries by conducting text mining on social media in countries with different substance management policies.

METHODS

We collected posts from Reddit and Xiaohongshu, conducted topic mining using the latent Dirichlet allocation model, and analyzed the characteristics of topics on different social media. Subsequently, a co-occurrence network of high-frequency keywords was constructed to explore potential relationships among topics. Moreover, we conducted sentiment analysis on the posts' comments and compared users' attitudes toward CBD products on Reddit and Xiaohongshu using chi-square test.

RESULTS

CBD-related posts on social media have been rapidly increasing, especially on Xiaohongshu since 2019. A total of 1790 posts from Reddit and 1951 posts from Xiaohongshu were included in the final analysis. The posts on the 2 social media platforms, Reddit and Xiaohongshu, were categorized into 7 and 8 topics, respectively, by the latent Dirichlet allocation model, and these topics on the 2 social media were grouped into 5 themes. Our study showed that the themes on Reddit were mainly related to the therapeutic effects of CBD, whereas the themes on Xiaohongshu concentrated on cosmetics, such as facial masks. Theme 2 (CBD market information) and theme 3 (attitudes toward CBD) on Reddit had more connections with other themes in the co-occurrence network, and theme 3 and theme 1 (CBD therapeutic effects) had a high co-occurrence frequency (22,803/73,865, 30.87%). Meanwhile, theme 1 (CBD cosmetics) on Xiaohongshu had various connections with others (169,961/384,575, 44.19%), and the co-occurrence frequency of theme 4 (CBD ingredients) and theme 1 was relatively prominent (27,128/49,312, 55.01%). Overall, users' comments tended to be positive for CBD-related information on both Reddit and Xiaohongshu, but the percentage was higher on Xiaohongshu (82.25% vs 86.18%; P<.001), especially in cosmetics and medical health care products.

CONCLUSIONS

The CBD market has grown rapidly, and the topics related to CBD on social media have become active. There are apparent differences in users' attitudes toward CBD in countries with different substance management policies. Targeted CBD management measures should be formulated to suit the prevalence of CBD use of each country.

The role of cannabis clinics in the health system: a qualitative study of physicians' views in New Zealand

BACKGROUND

Privately-owned cannabis clinics have sprung up in many jurisdictions where medicinal cannabis has been legalised and provide an alternative pathway for patients who are unable or unwilling to access a prescription for cannabis-based medicinal products from their usual healthcare providers.

AIMS

This study aimed to explore physicians' views on cannabis clinics, including their perceptions of the role cannabis clinics play in the wider health system.

METHODS

A qualitative study using in-depth, semi-structured interviews with thirty-one physicians affiliated with private and community clinics in New Zealand (including cannabis clinicians, GPs, and specialist doctors). The interviews were conducted from July to December 2021. Data were transcribed and analysed using inductive thematic analysis.

RESULTS

Cannabis clinicians positioned themselves as (1) "service providers", facilitating consumer access to cannabis prescriptions and products, and (2) "educators", providing advice to patients and the wider physician community. While general practitioners and specialists recognised the benefits of specialised cannabis clinics (i.e., knowledge of products and a non-judgmental environment), they questioned the limited evidence of clinical efficacy for cannabis, potential financial conflicts of interests of cannabis clinicians that may blur their clinical judgement, and the risk of compartmentalising patients' healthcare.

CONCLUSIONS

Our paper raises a number of challenges with attempting to integrate cannabis clinics into the wider health system.

Long-Term, Self-Dosing CBD Users: Indications, Dosage, and Self-Perceptions on General Health/Symptoms and Drug Use

Introduction

Self-dosing of off-the-shelf cannabidiol (CBD) for a myriad of health conditions is common in the USA. These CBD products are often mislabeled, suggesting that much less or much more CBD is being consumed than indicated on the label. This study examined the relationship between long-term self-dosing of CBD and (a) indications and, when a verified concentration of CBD is being consumed, (b) the daily CBD dosage, (c) the impact on general health and symptoms, and (d) over-the-counter (OTC) and prescription (Rx) drug usage.

Methods

US adults 18-75 years of age who had used unverified CBD products for >1 month were recruited to participate in this decentralized, observational, IRB-approved study and provided a concentration-verified CBD product of their choice from 15 different vendors for 4 weeks. Prior to receiving product, they were queried on their primary reason for use (PRfU), primary symptom for use (PSfU), general health score (GHS), symptom score (SS), OTC and Rx drug use, and daily CBD dose. Individuals were queried daily on OTC and Rx drug use and CBD dose and weekly on SS and GHS prior to (pre-CBD) and after (post-CBD) ingestion of CBD on that day.

Results

The PRfU included chronic pain, mental health, general health and wellness, sleep disorders, the central nervous system, digestive health, and others, while the PSfU included anxiety, back and/or joint pain, sleep, inflammation, and others. The mean daily dose was normally distributed, with a mean, median, and range of 53.1, 40.8, 8-390 mg/day, respectively. For both GHS and SS, the post-CBD was significantly higher than the pre-CBD score for each category of PRfU. The GHS scores did not change over the study, but pre- and post-CBD SS improved over time, with pre-improving more than post-CBD SS. The percentage of individuals decreasing or completely stopping OTC drugs or Rx drugs over the 4 weeks was 31.2% and 19.2%, respectively, with those taking CBD for chronic pain, decreasing drug use the most. OTC and Rx drug usage decreased when the CBD dose was changed and when GHS and SS improved.

Conclusion

Pain, mental health (primarily anxiety/stress), and sleep are the most common reasons for CBD use. Self-administration of CBD reduced OTC and Rx drug usage at daily doses less than those reported in controlled studies. CBD self-administration significantly improves self-perception of general health and decreases symptom severity, and as these improve, fewer OTC and Rx drugs are used.

Will tetrahydrocannabinol be formed from cannabidiol in gastric fluid? An in vivo experiment

Cannabidiol (CBD) products have ascribed an uprising trend for their health-promoting effects worldwide. In contrast to Δ⁹-tetrahydrocannabinol (THC), CBD exhibits no state of euphoria. Since conversion of CBD into THC in an acidic environment has been reported, it has not been proved whether this degradation will also occur in human gastric fluid. A total of 9 subjects ingested 400 mg CBD as a water-soluble liquid together with lecithin as an emulsifier and ethanol as a solubilizer. Blood samples were taken up to 4 h, and urine samples were submitted up to 48 h. THC, 11-hydroxy-Δ⁹-THC (THC-OH), 11-nor-9-carboxy-Δ⁹-THC (THC-COOH), CBD, 7-hydroxy cannabidiol (7-OH-CBD), and 7-carboxy cannabidiol (7-CBD-COOH) were determined in blood and THC-COOH and 7-CBD-COOH in urine by LC-MS/MS. Neither THC, THC-OH, nor THC-COOH were detectable in any serum specimen. Only two urine samples revealed THC-COOH values slightly above the threshold of 10 ng/ml, which could also be caused by trace amounts of THC being present in the CBD liquid. It can be concluded that negative consequences for participants of a drug testing program due to a conversion of CBD into THC in human gastric fluid appear unlikely, especially considering a single intake of dosages of less than 400 mg. Nevertheless, there is a reasonable risk for consumers of CBD products being tested positive for THC or THC metabolites. However, this is probably not caused by CBD cyclization into THC in human gastric fluid but is most likely due to THC being present as an impurity of CBD products.

Knowledge, experiences, and attitudes of Australian General Practitioners towards medicinal cannabis: a 2021-2022 survey

BACKGROUND

Medicinal cannabis (MC) products have been available on prescription in Australia for around six years. General practitioners (GPs) are at the forefront of MC prescribing and recent years have seen substantial increases in prescription numbers. This study examined the current knowledge, experiences, and attitudes of Australian GPs around MC. We also compared our findings to those of an earlier 2017 investigation.

METHOD

We conducted a cross-sectional study using a 42-item on-line questionnaire adapted from our earlier 2017 survey. The current survey was completed by GPs attending an on-line, multi-topic educational seminar. Australian GPs (n = 505) completed the survey between November 2021 and February 2022. Data were synthesised using descriptive statistics. MC 'prescribers' and 'non-prescribers' responses were compared using Pearson's χ2 tests.

RESULTS

While most GPs (85.3%) had received patient enquiries about MC during the last three months, only half (52.3%) felt comfortable discussing MC with patients. Around one fifth (21.8%) had prescribed a MC product. GPs strongly supported MC prescribing for palliative care, cancer pain, chemotherapy-induced nausea and vomiting, and epilepsy, more so than in our 2017 survey. Prescribing for mental health conditions (e.g., depression, anxiety) and insomnia received less support. Opioids, benzodiazepines, and chemotherapy drugs were rated as more hazardous than MC. GPs correctly endorsed concerns around Δ⁹-tetrahydrocannabinol-related driving impairment and drug-seeking behaviour. However, additional concerns endorsed around cannabidiol causing addiction and driving impairment do not agree with current evidence. Consistent with this, many GPs (66.9%) felt they had inadequate knowledge of MC.

CONCLUSION

Acceptance of MC as a treatment option has increased among Australian GPs since 2017. However, there is a clear need for improved training and education of GPs around cannabis-based medicines to provide increased numbers of skilled prescribers in the community.

Real-Time Monitoring of the Cytotoxic and Antimetastatic Properties of Cannabidiol in Human Oral Squamous Cell Carcinoma Cells Using Electric Cell-Substrate Impedance Sensing

Cannabidiol (CBD) is an active natural compound that is extracted from Cannabis sativa. Previous studies show that CBD is a nonpsychotropic compound with significant anticancer effects. This study determines its cytotoxic effect on oral cancer cells and OEC-M1 cells and compares the outcomes with a chemotherapeutic drug, cisplatin. This study has investigated the effect of CBD on the viability, apoptosis, morphology, and migration of OEC-M1 cells. Electric cell-substrate impedance sensing (ECIS) is used to measure the change in cell impedance for cells that are treated with a series concentration of CBD for 24 h. AlamarBlue and annexin V/7-AAD staining assays show that CBD has a cytotoxic effect on cell viability and induces cell apoptosis. ECIS analysis shows that CBD decreases the overall resistance and morphological parameters at 4 kHz in a concentration-dependent manner. There is a significant reduction in the wound-healing recovery rate for cells that are treated with 30 μM CBD. This study demonstrates that ECIS can be used for in vitro screening of new chemotherapy and is more sensitive, functional, and comprehensive than traditional biochemical assays. CBD also increases cytotoxicity on cell survival and the migration of oral cancer cells, so it may be a therapeutic drug for oral cancer.

CBD Oil as a Miracle Drug: A Thematic Analysis of Caregivers’ Attitudes and Practices Towards Cannabidiol in Dementia Treatment

The aim of this study was to understand caregivers of individuals with dementia attitudes toward CBD oil. Thematic analysis was conducted with 67 posts (570 comments) about CBD oil selected from a Polish online support forum for caregivers. We identified caregivers’ expectations, motivations, and practices of using CBD oil. Caregivers expected CBD to improve the behavior, cognition, communication, and daily activities of their loved ones. They motivated each other by sharing experiences about the positive effects of CBD oil and claimed to be administering CBD oil without medical advice, which led to dangerous practices such as an overnight withdrawal of all drugs or experimenting with CBD oil dosage. Caregivers perceive CBD oil as a safer and more effective treatment for those with dementia than the conventional methods. We recommend healthcare professionals inquire about possible CBD oil usage during follow-up visits and thoroughly explain what to expect from prescribed medications.

Effects of cannabidiol on simulated driving and cognitive performance: A dose-ranging randomised controlled trial

BACKGROUND

Cannabidiol (CBD), a major cannabinoid of Cannabis sativa, is widely consumed in prescription and non-prescription products. While CBD is generally considered 'non-intoxicating', its effects on safety-sensitive tasks are still under scrutiny.

AIM

We investigated the effects of CBD on driving performance.

METHODS

Healthy adults (n = 17) completed four treatment sessions involving the oral administration of a placebo, or 15, 300 or 1500 mg CBD in a randomised, double-blind, crossover design. Simulated driving performance was assessed between ~45-75 and ~210-240 min post-treatment (Drives 1 and 2) using a two-part scenario with 'standard' and 'car following' (CF) components. The primary outcome was standard deviation of lateral position (SDLP), a well-established measure of vehicular control. Cognitive function, subjective experiences and plasma CBD concentrations were also measured. Non-inferiority analyses tested the hypothesis that CBD would not increase SDLP by more than a margin equivalent to a 0.05% blood alcohol concentration (Cohen's d_z = 0.50).

RESULTS

Non-inferiority was established during the standard component of Drive 1 and CF component of Drive 2 on all CBD treatments and during the standard component of Drive 2 on the 15 and 1500 mg treatments (95% CIs < 0.5). The remaining comparisons to placebo were inconclusive (the 95% CIs included 0 and 0.50). No dose of CBD impaired cognition or induced feelings of intoxication (ps > 0.05). CBD was unexpectedly found to persist in plasma for prolonged periods of time (e.g. >4 weeks at 1500 mg).

CONCLUSION

Acute, oral CBD treatment does not appear to induce feelings of intoxication and is unlikely to impair cognitive function or driving performance (Registration: ACTRN12619001552178).

Effects of Cannabidiol on Exercise Physiology and Bioenergetics: A Randomised Controlled Pilot Trial

Background

Cannabidiol (CBD) has demonstrated anti-inflammatory, analgesic, anxiolytic and neuroprotective effects that have the potential to benefit athletes. This pilot study investigated the effects of acute, oral CBD treatment on physiological and psychological responses to aerobic exercise to determine its practical utility within the sporting context.

Methods

On two occasions, nine endurance-trained males (mean ± SD V̇O_2max: 57.4 ± 4.0 mL·min⁻¹·kg⁻¹) ran for 60 min at a fixed intensity (70% V̇O_2max) (RUN 1) before completing an incremental run to exhaustion (RUN 2). Participants received CBD (300 mg; oral) or placebo 1.5 h before exercise in a randomised, double-blind design. Respiratory gases (V̇O₂), respiratory exchange ratio (RER), heart rate (HR), blood glucose (BG) and lactate (BL) concentrations, and ratings of perceived exertion (RPE) and pleasure–displeasure were measured at three timepoints (T1–3) during RUN 1. V̇O_2max, RER_max, HR_max and time to exhaustion (TTE) were recorded during RUN 2. Venous blood was drawn at Baseline, Pre- and Post-RUN 1, Post-RUN 2 and 1 h Post-RUN 2. Data were synthesised using Cohen’s d_z effect sizes and 85% confidence intervals (CIs). Effects were considered worthy of further investigation if the 85% CI included ± 0.5 but not zero.

Results

CBD appeared to increase V̇O₂ (T2: + 38 ± 48 mL·min⁻¹, d_z: 0.25–1.35), ratings of pleasure (T1: + 0.7 ± 0.9, d_z: 0.22–1.32; T2: + 0.8 ± 1.1, d_z: 0.17–1.25) and BL (T2: + 3.3 ± 6.4 mmol·L⁻¹, d_z: > 0.00–1.03) during RUN 1 compared to placebo. No differences in HR, RPE, BG or RER were observed between treatments. CBD appeared to increase V̇O_2max (+ 119 ± 206 mL·min⁻¹, d_z: 0.06–1.10) and RER_max (+ 0.04 ± 0.05 d_z: 0.24–1.34) during RUN 2 compared to placebo. No differences in TTE or HR_max were observed between treatments. Exercise increased serum interleukin (IL)-6, IL-1β, tumour necrosis factor-α, lipopolysaccharide and myoglobin concentrations (i.e. Baseline vs. Post-RUN 1, Post-RUN 2 and/or 1-h Post-RUN 2, p’s < 0.05). However, the changes were small, making it difficult to reliably evaluate the effect of CBD, where an effect appeared to be present. Plasma concentrations of the endogenous cannabinoid, anandamide (AEA), increased Post-RUN 1 and Post-RUN 2, relative to Baseline and Pre-RUN 1 (p’s < 0.05). CBD appeared to reduce AEA concentrations Post-RUN 2, compared to placebo (− 0.95 ± 0.64 pmol·mL⁻¹, d_z: − 2.19, − 0.79).

Conclusion

CBD appears to alter some key physiological and psychological responses to aerobic exercise without impairing performance. Larger studies are required to confirm and better understand these preliminary findings.

Trial Registration This investigation was approved by the Sydney Local Health District’s Human Research Ethics Committee (2020/ETH00226) and registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12620000941965).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40798-022-00417-y.

Cannabis sativa Cannabinoids as Functional Ingredients in Snack Foods-Historical and Developmental Aspects

The published health benefits of Cannabis sativa has caught the attention of health-conscious consumers and the food industry. Historically, seeds have long been utilized as a food source and currently there is an increasing number of edibles on the market that contain cannabis. Cannabinoids include the psychoactive constituent, delta-9-tetrahydrocannabinol (THC), and the non-psychoactive cannabidiol (CBD) that are both compounds of interest in Cannabis sativa. This paper looks at the distribution of nutrients and phytocannabinoids in low-THC Cannabis sativa, the historical uses of hemp, cannabis edibles, and the possible side-effects and concerns related to cannabis edibles. Several authors have pointed out that even though the use of cannabis edibles is considered safe, it is important to mention their possible side-effects and any concerns related to its consumption that negatively influence consumer acceptance of cannabis edibles. Such risks include unintentional overdose by adults and accidental ingestion by children and adolescents resulting in serious adverse effects. Therefore, cannabis edibles should be specifically packaged and labelled to differentiate them from known similar non-cannabis edibles so that, together with tamperproof packaging, these measures reduce the appeal of these products to children.

Young adults' knowledge, perceptions and use of cannabidiol products: a mixed-methods study

Cannabidiol (CBD) product regulatory efforts must be informed by research regarding consumer perceptions. This mixed-methods study examined CBD product information sources, knowledge, perceptions, use and use intentions among young adults. This study analyzed (i) Fall 2020 survey data from 2464 US young adults (Mage = 24.67, 51.4% ever users, 32.0% past 6-month users) and (ii) Spring 2021 qualitative interviews among 40 survey participants (27.5% past-month users). Overall, 97.9% of survey participants reported having heard of CBD, 51.4% ever/lifetime use and 32.0% past 6-month use. Survey participants learned about CBD from friends/family (58.9%), products/ads at retailers (36.4%), online content/ads (34.8%), CBD stores (27.5%) and social media (26.7%). One-fourth believed that CBD products were required to be US Food and Drug Administration-approved (24.9%), tested for safety (28.8%) and proven effective to be marketed for pain, anxiety, sleep, etc. (27.2%). Survey and interview participants perceived CBD as safe, socially acceptable and effective for addressing pain, anxiety and sleep. Interview findings expanded on prominent sources of marketing and product exposure, including online and specialty retailers (e.g. vape shops), and on participants' concerns regarding limited regulation and/or evidence regarding CBD's effectiveness/risks. Given young adults' misperceptions about CBD, surveillance of CBD knowledge, perceptions and use is critical as the CBD market expands.

Medical cannabis, CBD wellness products and public awareness of evolving regulations in the United Kingdom

BACKGROUND

In the UK, legislation and regulations governing medical cannabis and over the counter cannabidiol (CBD) wellness products have rapidly evolved since 2018. This study aimed to assess the public awareness of the availability, regulations, and barriers to access medical cannabis and over the counter CBD wellness products.

METHODS

A cross-sectional survey study was performed through YouGov® using quota sampling methodology between March 22nd and March 31st 2021. Responses were matched and statistically weighted to UK adult population demographics, including those without internet access, and analysed according to percentage of respondents. Statistical significance was defined by p-value < 0.050.

RESULTS

Ten thousand six hundred eighty-four participants completed the survey. 5,494 (51.4%) respondents believed that medical cannabis is legal in the UK. 684 (6.4%) participants consumed CBD for wellness reasons, 286 (2.7%) were prescribed CBD for a medical reason and 222 (2.1%) consumed CBD for another reason. 10,076 (94.3%) respondents were unaware of April 2021 regulations meaning that all over the counter CBD wellness products in the UK must conform to European Novel Foods Regulations. The most frequently reported main barriers to accessing medical cannabis were its association with recreational cannabis (n = 2,686; 25.1%), being unsure if it was legal (n = 2,276; 21.3%) and being unsure what medical conditions its can be used for (n = 1,863; 17.4%).

CONCLUSION

A large proportion of respondents are unaware of the legislation and regulations surrounding medical cannabis and over the counter CBD wellness products. Lack of knowledge may present a barrier to safe access to either product.

The safety and efficacy of low oral doses of cannabidiol: An evaluation of the evidence

Global interest in the non-intoxicating cannabis constituent, cannabidiol (CBD), is increasing with claims of therapeutic effects across a diversity of health conditions. At present, there is sufficient clinical trial evidence to support the use of high oral doses of CBD (e.g., 10-50 mg/kg) in treating intractable childhood epilepsies. However, a question remains as to whether "low-dose" CBD products confer any therapeutic benefits. This is an important question to answer, as low-dose CBD products are widely available in many countries, often as nutraceutical formulations. The present review therefore evaluated the efficacy and safety of low oral doses of CBD. The review includes interventional studies that measured the clinical efficacy in any health condition and/or safety and tolerability of oral CBD dosed at less than or equal to 400 mg per day in adult populations (i.e., ≥18 years of age). Studies were excluded if the product administered had a Δ⁹ -tetrahydrocannabinol content greater than 2.0%. Therapeutic benefits of CBD became more clearly evident at doses greater than or equal to 300 mg. Increased dosing from 60 to 400 mg/day did not appear to be associated with an increased frequency of adverse effects. At doses of 300-400 mg, there is evidence of efficacy with respect to reduced anxiety, as well as anti-addiction effects in drug-dependent individuals. More marginal and less consistent therapeutic effects on insomnia, neurological disorders, and chronic pain were also apparent. Larger more robust clinical trials are needed to confirm the therapeutic potential of lower (i.e., <300 mg/day) oral doses of CBD.

The Effects of Cannabidiol on Aqueous Humor Outflow and Trabecular Meshwork Cell Signaling

Intraocular pressure (IOP) is regulated primarily through aqueous humor production by ciliary body and drainage through uveoscleral and trabecular meshwork (TM) tissues. The goal of this study was to measure the effect of non-psychotropic cannabidiol (CBD) on aqueous humor outflow through TM and assess the effect of CBD on the TM cell signaling pathways that are important for regulating outflow. Perfused porcine eye anterior segment explants were used to investigate the effects of CBD on aqueous humor outflow. Cultured porcine TM cells were used to study the effects of CBD on TM cell contractility, myosin light chain (MLC) and myosin phosphatase targeting subunit 1 (MYPT1) phosphorylation, and RhoA activation. In the anterior segment perfusion experiments, aqueous humor outflow was increased significantly within 1 h after adding 1 µM CBD and the effect was sustained over the 5 h of measurement. Treatment of TM cells with 1 µM CBD significantly decreased TM cell-mediated collagen contraction, inhibited phosphorylation of MLC and MYPT1, and reduced RhoA activation. Our data demonstrate, for the first time, that as a potential therapeutic agent for lowering intraocular pressure, CBD can enhance aqueous humor outflow and modify TM cell signaling.

Regulating for Safety: Cannabidiol Dose in Food: A Review

ABSTRACT

Cannabidiol (CBD) is a nonpsychoactive phytocannabinoid and hemp derivative increasingly used in food. Illegal in food at the U.S. federal level, but legal in some states, the CBD-infused food product market has grown substantially, prompting government concerns regarding potential safety risks. CBD foods are a growing market that is driven by increasing demand from producers and consumers and that is governed by an inconsistent and evolving legal framework. This systematic review of research and regulations identified how legality relates to safety. The research also included an emphasis on dose, a key factor for determining safety in foods. Statutes and guidance documents were reviewed from a selection of jurisdictions with existing or proposed legalized CBD in food to determine what restrictions are used relative to safety, including dose and related standards for food. A search of scientific literature was conducted to evaluate what is known about safe dose in food applications and determine what information is still needed to inform a standard or regulated limit. Findings were analyzed to determine risks and what research and regulations are needed to address them. Legal jurisdictions do little to safeguard consumers against potential risks associated with CBD in food because they focus primarily on warnings and prohibiting health claims. Warning and labeling requirements lack consistency. More concerning is the absence of standards for dose in food or for the composition of the CBD used. Further, there is limited and incomplete information to inform such standards.

HIGHLIGHTS

Topical Cannabidiol (CBD) After Total Knee Arthroplasty Does Not Decrease Pain or Opioid Use: A Prospective Randomized Double-Blinded Placebo-Controlled Trial

BACKGROUND

Multimodal analgesia has become the standard of care for pain management following total knee arthroplasty (TKA). Cannabidiol (CBD) is increasingly utilized in the postoperative period. The purpose of this study was to analyze the analgesic benefits of topical CBD following primary TKA.

METHODS

In this randomized double-blinded placebo-controlled trial, 80 patients undergoing primary unilateral TKA applied topical CBD (CBD; n = 19), essential oil (EO; n = 21), CBD and essential oil (CBD + EO; n = 21), or placebo (PLA; n = 19) thrice daily around the knee for two weeks postoperatively. This supplemented a standardized multimodal analgesic protocol. Outcomes included visual analog scale (VAS) pain and numeric rating scale (NRS) sleep scores (collected on postoperative day [POD] 0, 1, 2, 7, 14, 42), and cumulative postoperative opioid use (42 days).

RESULTS

Demographic characteristics were similar among the four cohorts. Preoperative VAS and NRS scores were similar among groups. The CBD cohort had a higher mean VAS pain score on POD 2 compared to the EO cohort (CBD: 69.9 ± 19.3 versus. EO: 51.0 ± 18.2; P = .013). No statistically significant differences existed for VAS scores at other times, and no statistically significant differences were observed for postoperative NRS sleep scores or postoperative opioid use at any time point.

CONCLUSION

Utilization of topical CBD in supplement to multimodal analgesia did not reduce pain or opioid consumption, or improve sleep scores following TKA. These results suggest that the local effects of topical CBD are not beneficial for providing additional pain relief after TKA.

Neuroprotection of Cannabidiol, Its Synthetic Derivatives and Combination Preparations against Microglia-Mediated Neuroinflammation in Neurological Disorders

The lack of effective treatment for neurological disorders has encouraged the search for novel therapeutic strategies. Remarkably, neuroinflammation provoked by the activated microglia is emerging as an important therapeutic target for neurological dysfunction in the central nervous system. In the pathological context, the hyperactivation of microglia leads to neuroinflammation through the release of neurotoxic molecules, such as reactive oxygen species, proteinases, proinflammatory cytokines and chemokines. Cannabidiol (CBD) is a major pharmacologically active phytocannabinoids derived from Cannabis sativa L. CBD has promising therapeutic effects based on mounting clinical and preclinical studies of neurological disorders, such as epilepsy, multiple sclerosis, ischemic brain injuries, neuropathic pain, schizophrenia and Alzheimer’s disease. A number of preclinical studies suggested that CBD exhibited potent inhibitory effects of neurotoxic molecules and inflammatory modulators, highlighting its remarkable therapeutic potential for the treatment of numerous neurological disorders. However, the molecular mechanisms of action underpinning CBD’s effects on neuroinflammation appear to be complex and are poorly understood. This review summarises the anti-neuroinflammatory activities of CBD against various neurological disorders with a particular focus on their main molecular mechanisms of action, which were related to the downregulation of NADPH oxidase-mediated ROS, TLR4-NFκB and IFN-β-JAK-STAT pathways. We also illustrate the pharmacological action of CBD’s derivatives focusing on their anti-neuroinflammatory and neuroprotective effects for neurological disorders. We included the studies that demonstrated synergistic enhanced anti-neuroinflammatory activity using CBD and other biomolecules. The studies that are summarised in the review shed light on the development of CBD, including its derivatives and combination preparations as novel therapeutic options for the prevention and/or treatment of neurological disorders where neuroinflammation plays an important role in the pathological components.

Cannabinoid consumption among cancer patients receiving systemic anti-cancer treatment in the Netherlands

PURPOSE

Despite the inconclusiveness regarding health effects of cannabinoids among cancer patients, studies from non-European countries suggest that the medical-intended consumption of such products by this patient group is significant. The current study analyses cannabinoid usage among oncology patients receiving systemic treatment in the Netherlands.

METHODS

The current study included adult patients receiving intravenous systemic therapy at Maastricht Comprehensive Cancer Centre, for a solid malignancy. Participants were asked to complete an anonymous questionnaire including questions on demographic variables, clinical variables and cannabinoid consumption.

RESULTS

A total of 153 patients with solid cancer were included in this study. Almost 25% reported usage of cannabinoids for medical purposes, with 15% of the patients currently using the substance. Additionally, 18% of non-users considered future medical usage. In 48% of the cases, consumption was reported by the oncologist. The proposed anti-cancer effect was reported by 46% of the users as motivation for consumption. Current users were mainly palliative patients and 54% of the users were undergoing immunotherapy. Intention of treatment and type of therapy were predictive factors for consumption. Cannabinoid-oil was the most frequently used way of consumption.

CONCLUSION

This study underlines the high number of cannabinoid users among oncology patients in the Netherlands in presumed absence of clinical guidance. It highlights the essence of a pro-active role of the clinician, assessing cannabinoid usage and educating the patients on the most recent evidence regarding its potential benefits and risks. Further studies on clinical decision making and efficacy of cannabinoids are recommended, to improve clinical guidance.

The Role of Cannabis, Cannabidiol and Other Cannabinoids in Chronic Pain. The Perspective of Physicians

Currently, there is a renewed interest in treatments with medical cannabis and cannabinoids. Based on an increasing number of publications over the last decades that permitted new insights into mechanisms, efficacy and safety of cannabinoids, the use of cannabinergic medications is authorised in an increasing number of European and non-European countries. The alleviation of chronic, painful conditions is, since thousands of years, one of the primary reasons for the use of cannabis. Depending on the country, a wide range of medicinal cannabis preparations are available:ranging from defined cultivars of medical cannabis, mainly varying in their THC:CBD ratio, that are inhaled or taken as whole plant extracts,to highly purified single cannabinoids, such as delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD),or mixtures of two enriched extracts, standardised to a 1:1 ratio of THC:CBD (nabiximols). Although conflicting opinions continue to exist, the majority of reviews in the past concluded that medical cannabis and cannabinoids play a significant role in the management of pain. Surprisingly, systematic studies to date do not support an "entourage effect" of the other plant constituents of cannabis (mainly terpenoids) in treatment of chronic pain. An emerging cannabinoid is CBD which is the only cannabinergic medication available at present that does not cause the typical "cannabis high"; it is not a "controlled substance". However, despite years of research, there is either no study or no well-conducted, head-to-head, comparison available between different cannabis cultivars, between pure cannabinoids, and between pure cannabinoids and extracts. It remains unanswered which is the optimal treatment approach.

Over the counter low-dose cannabidiol: A viewpoint from the ACRE Capacity Building Group

Amidst growing global acceptance of medicinal cannabinoids as a potential therapeutic interest in cannabidiol (CBD) is increasing. In Australia in 2020, a government inquiry examined the barriers that the public are experiencing in accessing medicinal cannabis. A number of recommendations to improve access were made. In response to these recommendations, the Australian therapeutics regulatory authority down-scheduled CBD from Prescription Only (Schedule 4) to Pharmacist Only (Schedule 3). As a group of early to mid-career researchers of the Australian Centre for Cannabinoid Clinical and Research Excellence (ACRE), we propose some considerations in relation to over-the-counter availability of CBD and opportunities to improve knowledge about its potential therapeutic benefits alongside its increased uptake.

Is Cannabis Legalization Eliciting Abusive Behaviors in Parents? A Case Report

The interest in cannabis, cannabis-based compounds, and treatments is rapidly growing along with the legalization of marijuana in many countries and widespread use of cannabis derivatives in medical products. A growing body of literature is warning about possible unintentional intoxication in children because of unregulated and unsupervised use of cannabinoids by parents; to our knowledge, very rarely have parental self-prescription and self-administration to their children (affected by neurologic or other disorders or no disorders at all) been reported. We report a 4-year-old child, suffering from an anti-N-methyl-D-aspartate receptor encephalitis, who was found unpredictably positive for cannabis and other illicit substances after drug testing was performed in order to investigate the child's treatment-resistant behavioral disturbances. Toxicologic analyses were also extended to the child's parents, who finally disclosed that they had deliberately administered a cannabis-derived product (cannabidiol extract) as a home remedy for managing their child's behavior. Careless with regard to the possible adverse effects and certain that the product was legal, they presumed there was no need for them to inform the physicians in charge of treating the child of this practice.

Does Cannabidiol Have a Benefit as a Supportive Care Drug in Cancer?

OPINION STATEMENT

Cannabinoids have been purported as having a wide range of therapeutic uses although currently, there is minimal evidence to support these claims. Patients with advanced cancer experience many distressing symptoms, with some turning to medicinal cannabis to help alleviate these. Focus has fallen on cannabidiol (CBD) as a potential treatment for a variety of symptoms in advanced cancer due to the lack of psychoactive side effects and the potential molecular mechanisms of action associated with this cannabinoid. Many cannabinoid products are easily available in the community, and more countries are legalizing or allowing over the counter products. Studies show that CBD is generally well tolerated, but there are many potential drug interactions that have not been well studied. Few studies have specifically looked at the role of CBD in treating cancer symptoms, with most focusing on combination cannabinoid products. There are currently many unknowns associated with CBD, including which symptoms it might be best for, appropriate dosing, and route of administration. This is especially important in advanced cancer where patients often have significant organ dysfunction and frailty that could impact on the pharmacology of CBD. A small pilot study has shown promise for a role of CBD in the psychological symptoms associated with advanced cancer. Further research is currently underway to further clarify the role of CBD in this setting and to understand how best it might help our patients. Currently we advocate that CBD be used in supervised clinical trials, so that efficacy and adverse effects can be closely monitored.

Quantitative determination of five cannabinoids in blood and urine by gas chromatography tandem mass spectrometry applying automated on-line solid phase extraction

Cannabis is the most frequently consumed illegal substance worldwide. More recently, an increasing number of legal cannabis products low in psychoactive Δ⁹‐tetrahydrocannabinol (THC) but high in non‐intoxicating cannabidiol (CBD) are being more widely consumed. While the detection and quantification of THC and its metabolites in biological matrices is an important forensic‐toxicological task, additional detection of CBD is also important, for example, when examining the plausibility of consumer's statements. This report describes the method validation for the quantitative determination of THC and its two major metabolites, 11‐hydroxy‐THC (OH‐THC) and 11‐nor‐9‐carboxy‐THC (THC‐COOH), as well as CBD and cannabinol (CBN) in whole blood and urine. The method employs automated on‐line solid phase extraction coupled to gas chromatography tandem mass spectrometry (GC–MS/MS). The method was fully validated according to guidelines of the Swiss Society of Legal Medicine (SGRM) and the Society of Toxicological and Forensic Chemistry (GTFCh). The method fulfilled the validation criteria regarding analytical limits, accuracy and precision, extraction efficacy, and sample stability. The limits of detection (LODs) in whole blood and urine were 0.15 ng/mL for THC, OH‐THC and CBD, 0.1 ng/mL for CBN, and 1.0 ng/mL for THC‐COOH. The limits of quantification (LOQ) in whole blood and urine were 0.3 ng/mL for THC, OH‐THC and CBD, 0.2 ng/mL for CBN, and 3.0 ng/mL for THC‐COOH. The fully validated and automated method allows sensitive and robust measurement of cannabinoids in whole blood and urine. Detection of CBD provides additional information regarding consumed products.

LC-MS/MS Assay for the Measurement of Cannabidiol Profiling in CBD Oil from Japanese Market and Application for Convertible Tetrahydrocannabinol in Acetic Acid Condition

Cannabidiol (CBD), a major non-psychoactive cannabinoid, has a lot of attention due to its potential relaxing properties and led the trend in commercial CBD aroma/oral hemp seed oil from the Japanese market. In this study, a routine assay for evaluating CBD oil samples was performed using LC coupled with tandem mass spectrometry (LC-MS/MS) and was used to apply the convertible tetrahydrocannabinol (THC) in acetic acid conditions. Based on the electrospray positive ion mode, the detection of cannabidiolic acid (CBDA; m/z 359 > 219), cannabigerolic acid (CBGA; m/z 361 > 343), cannabigerol (CBG; m/z 317 > 193), CBD (m/z 315 > 193), THC (m/z 315 > 193) and cannabinol (CBN; m/z 311 > 223) was performed by satisfying separation with high density of C₁₈ column. Oil samples (50 mg) were diluted with isopropanol (5 mL), to which stable isotope internal standards were added by dilution with methanol/water (50/50), and accuracy rates ranged from 97.8 to 102.2%. This method was used to evaluate the CBD oil products (5 kinds) from the Japanese market. Our survey found obvious counterfeit (non-detectable CBD) CBD oil from Japanese market. Following that, we investigated the conversion of THC in CBD oil samples in simple conditions such as 10% acetic acid and 70 °C for 6 h and discovered that converts THC proportions are approximately 5% ((THC content/CBD content) × 100) and <1.0%. Thus, our developed LC-MS/MS assay could be applied to monitor the CBD concentration and convertible THC from CBD oil.

Adulteration of low-THC products with synthetic cannabinoids: Results from drug checking services

Since late 2019, low‐delta‐9‐tetrahydrocannabinol (THC) preparations adulterated with synthetic cannabinoids (SCs) have been frequently observed in Switzerland. The unawareness of users concerning the presence of SCs and the typically higher potency and toxicity of SCs, when compared with THC, can result in increased health risks. In Switzerland, low‐THC (<1%) cannabis products, except hashish, are legal. These products can act as carrier materials for SCs. In this study, cannabis samples and user self‐reports received through three drug checking services were collected and analysed, to gain deeper insight into this new phenomenon. Samples were collected from January 2020 to July 2021. Liquid chromatography coupled with high‐resolution mass spectrometry was used for the qualitative screening and semi‐quantification of SCs, while gas chromatography with flame ionization detector was applied for the quantification of THC and cannabidiol levels. Reported adverse effects were compared between users who consumed adulterated (SC‐group) and non‐adulterated (THC‐group) products. Of a total 94 samples, 50% contained up to three different SCs. MDMB‐4en‐PINACA was most often detected. All adulterated cannabis flowers contained ≤1% THC. Adulterated hashish also typically presented low THC‐levels (median: 0.8%). The SC‐group was associated with higher numbers of adverse events (p = 0.041). Furthermore, psychologic (p = 0.0007) and cardiologic (p = 0.020) adverse effects were more profound in the SC‐group than in the THC‐group. Drug checking services enabled the timely detection and monitoring of new and potentially dangerous trends. Furthermore, due to user‐reports, additional valuable information was gained on adverse events associated with the consumption of novel SCs.

Staff awareness of the use of cannabidiol (CBD): a trust-wide survey study in the UK

INTRODUCTION

Cannabidiol (CBD) is now a legal substance in Europe and is available in 'high street shops', usually as CBD oil. However, in the United Kingdom (UK), there is no clear consensus among healthcare professionals and organisations over how to manage CBD use in their patients. This is an important issue as CBD is a constituent of 'medicinal and recreational cannabis' and is gaining support in the scientific literature and lay media for use in physical and mental health problems. Given the aforementioned, this study is an exploration of healthcare professionals' beliefs and attitudes with regard to CBD.

METHODS

In July 2018, we sent requests by email to approximately 2000 clinical staff (including 319 physicians) at a mental health trust in South West London to answer 8 questions in a single survey using Surveyplanet.com , about their beliefs regarding CBD. There was no specific method of choosing the staff, and the aim was to get the email request sent to as many staff as possible on each service line. We did an analysis to see how the attitudes and beliefs of different staff member groups compared. We also gave them space to offer free text responses to illustrate their ideas and concerns. We used chi-squared tests for comparison across groups and used odds ratio for pairwise group comparisons.

RESULTS

One hundred ninety surveys were received in response, and of these, 180 were included in the final sample. The physician response rate was 17.2% (55/319); the response rate for non-physicians could not be estimated as their total number was not known at outset. 32.2% of the responders had the right to prescribe (58/180) and 52.8% had an experience of working in addiction services (95/180). We found that staff members who can prescribe were 1.99 times as likely to believe CBD has potential therapeutic properties compared to those who do not (OR = 1.99, CI = 1.03, 3.82; p = 0.038) and 2.94 times less likely to think it had dangerous side effects (OR = 0.34, CI = 0.15, 0.75; p = 0.006). Prescribing healthcare professionals were 2.3 times as likely to believe that CBD reduces the likelihood of psychosis (OR = 2.30, CI = 1.10, 4.78; p = 0.024). However, prescribing healthcare professionals with the ability to prescribe were 2.12 times as likely to believe that CBD should be prescription only (OR = 2.12, CI = 1.12, 4.01; p = 0.02). Individuals experienced in addiction services were 2.22 times as likely to be associated with a belief that CBD has therapeutic properties (OR = 2.22, CI = 1.22, 4.04; p = 0.009). Staff in general reported a lack of knowledge about CBD in their free text responses.

CONCLUSIONS

With almost 95% of prescribers being physicians, they appear to demonstrate awareness of potential therapeutic benefit, reduced likelihood of psychosis and seeming lack of dangerous side effects with CBD. However, their higher stringency about the need for prescription implies an attitude of caution. There was also a suggestion that biases about cannabis were influencing responses to questions as well. The external validity of this study could be diminished by sampling bias and limitation to a single mental health trust. Nonetheless, some of the results drew a reasonable comparison with similar studies.

Cannabidiol Exposure During the Mouse Adolescent Period Is Without Harmful Behavioral Effects on Locomotor Activity, Anxiety, and Spatial Memory

Cannabidiol (CBD) is a non-intoxicating phytocannabinoid whose purported therapeutic benefits and impression of a high safety profile has promoted its increasing popularity. CBD’s popularity is also increasing among children and adolescents who are being administered CBD, off label, for the treatment of numerous symptoms associated with autism spectrum disorder, attention deficit hyperactivity disorder, anxiety, and depression. The relative recency of its use in the adolescent population has precluded investigation of its impact on the developing brain and the potential consequences that may present in adulthood. Therefore, there’s an urgency to identify whether prolonged adolescent CBD exposure has substantive impacts on the developing brain that impact behavioral and cognitive processes in adulthood. Here, we tested the effect of twice-daily intraperitoneal administrations of CBD (20 mg/kg) in male and female C57BL/6J mice during the adolescent period of 25–45 days on weight gain, and assays for locomotor behavior, anxiety, and spatial memory. Prolonged adolescent CBD exposure had no detrimental effects on locomotor activity in the open field, anxiety behavior on the elevated plus maze, or spatial memory in the Barnes Maze compared to vehicle-treated mice. Interestingly, CBD-treated mice had a faster rate of learning in the Barnes Maze. However, CBD-treated females had reduced weight gain during the exposure period. We conclude that prolonged adolescent CBD exposure in mice does not have substantive negative impacts on a range of behaviors in adulthood, may improve the rate of learning under certain conditions, and impacts weight gain in a sex-specific manner.

Citalopram and Cannabidiol: In Vitro and In Vivo Evidence of Pharmacokinetic Interactions Relevant to the Treatment of Anxiety Disorders in Young People

BACKGROUND

Cannabidiol (CBD), a major nonintoxicating constituent of cannabis, exhibits anxiolytic properties in preclinical and human studies and is of interest as a novel intervention for treating anxiety disorders. Existing first-line pharmacotherapies for these disorders include selective serotonin reuptake inhibitor and other antidepressants. Cannabidiol has well-described inhibitory action on cytochrome P450 (CYP450) drug-metabolizing enzymes and significant drug-drug interactions (DDIs) between CBD and various anticonvulsant medications (eg, clobazam) have been described in the treatment of epilepsy. Here, we examined the likelihood of DDIs when CBD is added to medications prescribed in the treatment of anxiety.

METHODS

The effect of CBD on CYP450-mediated metabolism of the commonly used antidepressants fluoxetine, sertraline, citalopram, and mirtazapine were examined in vitro. Cannabidiol-citalopram interactions were also examined in vivo in patients (n = 6) with anxiety disorders on stable treatment with citalopram or escitalopram who received ascending daily doses of adjunctive CBD (200-800 mg) over 12 weeks in a recent clinical trial.

RESULTS

Cannabidiol minimally affected the metabolism of sertraline, fluoxetine, and mirtazapine in vitro. However, CBD significantly inhibited CYP3A4 and CYP2C19-mediated metabolism of citalopram and its stereoisomer escitalopram at physiologically relevant concentrations, suggesting a possible in vivo DDI. In patients on citalopram or escitalopram, the addition of CBD significantly increased citalopram plasma concentrations, although it was uncertain whether this also increased selective serotonin reuptake inhibitor-mediated adverse events.

CONCLUSIONS

Further pharmacokinetic examination of the interaction between CBD and citalopram/escitalopram is clearly warranted, and clinicians should be vigilant around the possibility of treatment-emergent adverse effects when CBD is introduced to patients taking these antidepressants.

Orally administered cannabidiol does not produce false-positive tests for Δ9 -tetrahydrocannabinol on the Securetec DrugWipe® 5S or Dräger DrugTest® 5000

Many jurisdictions use point‐of‐collection (POC) oral fluid testing devices to identify driving under the influence of cannabis, indexed by the presence of Δ⁹‐tetrahydrocannabinol (THC), an intoxicating cannabinoid, in oral fluid. Although the use of the non‐intoxicating cannabinoid, cannabidiol (CBD), is not prohibited among drivers, it is unclear whether these devices can reliably distinguish between CBD and THC, which have similar chemical structures. This study determined whether orally administered CBD produces false‐positive tests for THC on standard, POC oral fluid testing devices. In a randomised, double‐blind, crossover design, healthy participants (n = 17) completed four treatment sessions involving the administration of either placebo or 15‐, 300‐ or 1500‐mg pure CBD in a high‐fat dietary supplement. Oral fluid was sampled, and the DrugWipe®‐5S (DW‐5S; 10 ng·ml⁻¹ THC cut‐off) and Drug Test® 5000 (DT5000; 10 ng·mL⁻¹ THC cut‐off) devices administered, at baseline (pretreatment) and ~20‐, ~145‐ and ~185‐min posttreatment. Oral fluid cannabinoid concentrations were measured using ultra‐high performance liquid chromatography–tandem mass spectrometry. Median (interquartile range [IQR]) oral fluid CBD concentrations were highest at ~20 min, quantified as 0.4 (6.0), 15.8 (41.6) and 167 (233) ng·ml⁻¹ on the 15‐, 300‐ and 1500‐mg CBD treatments, respectively. THC, cannabinol and cannabigerol were not detected in any samples. A total of 259 DW‐5S and 256 DT5000 tests were successfully completed, and no THC‐positive tests were observed. Orally administered CBD does not appear to produce false‐positive (or true‐positive) tests for THC on the DW‐5S and DT5000. The likelihood of an individual who is using a CBD (only) oral formulation being falsely accused of DUIC therefore appears low.

Cannabis constituents interact at the drug efflux pump BCRP to markedly increase plasma cannabidiolic acid concentrations

Cannabis is a complex mixture of hundreds of bioactive molecules. This provides the potential for pharmacological interactions between cannabis constituents, a phenomenon referred to as “the entourage effect” by the medicinal cannabis community. We hypothesize that pharmacokinetic interactions between cannabis constituents could substantially alter systemic cannabinoid concentrations. To address this hypothesis we compared pharmacokinetic parameters of cannabinoids administered orally in a cannabis extract to those administered as individual cannabinoids at equivalent doses in mice. Astonishingly, plasma cannabidiolic acid (CBDA) concentrations were 14-times higher following administration in the cannabis extract than when administered as a single molecule. In vitro transwell assays identified CBDA as a substrate of the drug efflux transporter breast cancer resistance protein (BCRP), and that cannabigerol and Δ⁹-tetrahydrocannabinol inhibited the BCRP-mediated transport of CBDA. Such a cannabinoid-cannabinoid interaction at BCRP transporters located in the intestine would inhibit efflux of CBDA, thus resulting in increased plasma concentrations. Our results suggest that cannabis extracts provide a natural vehicle to substantially enhance plasma CBDA concentrations. Moreover, CBDA might have a more significant contribution to the pharmacological effects of orally administered cannabis extracts than previously thought.

Immunomodulation by cannabinoids: Current uses, mechanisms, and identification of data gaps to be addressed for additional therapeutic application

The endocannabinoid system plays a critical role in immunity and therefore its components, including cannabinoid receptors 1 and 2 (CB₁ and CB₂), are putative druggable targets for immune-mediated diseases. Whether modulating endogenous cannabinoid levels or interacting with CB₁ or CB₂ receptors directly, cannabinoids or cannabinoid-based therapeutics (CBTs) show promise as anti-inflammatory or immune suppressive agents. Herein we provide an overview of cannabinoid effects in animals and humans that provide support for the use of CBTs in immune-mediated disease such as multiple sclerosis (MS), inflammatory bowel disease (IBD), asthma, arthritis, diabetes, human immunodeficiency virus (HIV), and HIV-associated neurocognitive disorder (HAND). This is not an exhaustive review of cannabinoid effects on immune responses, but rather provides: (1) key studies in which initial and/or novel observations were made in animal studies; (2) critical human studies including meta-analyses and randomized clinical trials (RCTs) in which CBTs have been assessed; and (3) evidence for the role of CB₁ or CB₂ receptors in immune-mediated diseases through genetic analyses of single nucleotide polymorphisms (SNPs) in the CNR1 and CNR2 genes that encode CB₁ or CB₂ receptors, respectively. Perhaps most importantly, we provide our view of data gaps that exist, which if addressed, would allow for more rigorous evaluation of the efficacy and risk to benefit ratio of the use of cannabinoids and/or CBTs for immune-mediated diseases.