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Moore A, Straube S, Fisher E, Eccleston C. Cannabidiol (CBD) Products for Pain: Ineffective, Expensive, and With Potential Harms. THE JOURNAL OF PAIN 2024; 25:833-842. [PMID: 37863344 DOI: 10.1016/j.jpain.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/29/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023]
Abstract
Cannabidiol (CBD) attracts considerable attention for promoting good health and treating various conditions, predominantly pain, often in breach of advertising rules. Examination of available CBD products in North America and Europe demonstrates that CBD content can vary from none to much more than advertised and that potentially harmful other chemicals are often included. Serious harm is associated with chemicals found in CBD products and reported in children, adults, and the elderly. A 2021 International Association for the Study of Pain task force examined the evidence for cannabinoids and pain but found no trials of CBD. Sixteen CBD randomized trials using pharmaceutical-supplied CBD or making preparations from such a source and with pain as an outcome have been published subsequently. The trials were conducted in 12 different pain states, using 3 oral, topical, and buccal/sublingual administration, with CBD doses between 6 and 1,600 mg, and durations of treatment between a single dose and 12 weeks. Fifteen of the 16 showed no benefit of CBD over placebo. Small clinical trials using verified CBD suggest the drug to be largely benign; while large-scale evidence of safety is lacking, there is growing evidence linking CBD to increased rates of serious adverse events and hepatotoxicity. In January 2023, the Food and Drug Administration (FDA) announced that a new regulatory pathway for CBD was needed. Consumers and health care providers should rely on evidence-based sources of information on CBD, not just advertisements. Current evidence is that CBD for pain is expensive, ineffective, and possibly harmful. PERSPECTIVE: There is no good reason for thinking that CBD relieves pain, but there are good reasons for doubting the contents of CBD products in terms of CBD content and purity.
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Affiliation(s)
| | - Sebastian Straube
- Division of Preventive Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Emma Fisher
- Centre for Pain Research, University of Bath, Claverton Down, Bath, UK
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2
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Singh Cham P, Kotwal P, Sharma K, Dhiman S, Singh L, Pratap Singh V, Kumar A, Nandi U, Pal Singh P. Cannabidiol-Based Prodrugs: Synthesis and Bioevaluation. ACS Med Chem Lett 2024; 15:221-229. [PMID: 38352838 PMCID: PMC10860190 DOI: 10.1021/acsmedchemlett.3c00461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 12/27/2023] [Accepted: 01/02/2024] [Indexed: 02/16/2024] Open
Abstract
Cannabidiol (CBD 1) is a nonpsychotic cannabinoid-based drug approved by the U.S. FDA for treating refractory epilepsy, namely, Lennox-Gastaut and Dravet syndrome. However, its low aqueous solubility and oral bioavailability are compensated by administering high doses, and there is an increased demand for conjugates with improved properties. In this direction, the present work is focused on synthesizing CBD-based prodrugs to address the issue of poor solubility and oral bioavailability. Several CBD-based prodrugs were synthesized and studied in a battery of assays: viz, release kinetic (ex vivo), solubility (in vitro), chemical stability (in vitro), plasma stability (ex vivo), pharmacokinetics (in vivo), and efficacy studies (in vivo). Among the synthesized prodrugs, the morpholinyl CBD-based prodrugs 3a and 3aa showed good release behavior, stability, better solubility, and a plasma profile. Moreover, prodrug candidate 3aa showed better therapeutic efficacy. The present study identifies CBD-based prodrugs with improved physiochemical properties and oral exposure.
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Affiliation(s)
- Pankaj Singh Cham
- Natural
Product & Medicinal Chemistry Division, CSIR-Indian Institute of Integrative Medicine (CSIR-IIIM), Canal Road, Jammu 180001, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Pankul Kotwal
- Pharmacology
Division, CSIR-Indian Institute of Integrative
Medicine (CSIR-IIIM), Canal Road, Jammu 180001, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Kuhu Sharma
- Pharmacology
Division, CSIR-Indian Institute of Integrative
Medicine (CSIR-IIIM), Canal Road, Jammu 180001, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Sumit Dhiman
- Pharmacology
Division, CSIR-Indian Institute of Integrative
Medicine (CSIR-IIIM), Canal Road, Jammu 180001, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Lakhvinder Singh
- Pharmacology
Division, CSIR-Indian Institute of Integrative
Medicine (CSIR-IIIM), Canal Road, Jammu 180001, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Varun Pratap Singh
- Natural
Product & Medicinal Chemistry Division, CSIR-Indian Institute of Integrative Medicine (CSIR-IIIM), Canal Road, Jammu 180001, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Ajay Kumar
- Pharmacology
Division, CSIR-Indian Institute of Integrative
Medicine (CSIR-IIIM), Canal Road, Jammu 180001, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Utpal Nandi
- Pharmacology
Division, CSIR-Indian Institute of Integrative
Medicine (CSIR-IIIM), Canal Road, Jammu 180001, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Parvinder Pal Singh
- Natural
Product & Medicinal Chemistry Division, CSIR-Indian Institute of Integrative Medicine (CSIR-IIIM), Canal Road, Jammu 180001, India
- Academy
of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
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3
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Cheng YC, Kerrigan S. Factors influencing the in situ formation of Δ9-THC from cannabidiol during GC-MS analysis. Drug Test Anal 2023. [PMID: 38049934 DOI: 10.1002/dta.3617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 12/06/2023]
Abstract
Gas chromatography-mass spectrometry (GC-MS) is widely used for the identification of cannabinoids in seized plant material. Conditions used for instrumental analysis should maximize decarboxylation, while minimizing the in situ production of Δ9-THC inside the GC inlet. In this study, decarboxylation of the acidic Δ9-THC precursor and in situ degradation of cannabidiol (CBD) were investigated using seven commercial GC liners with different deactivation chemistries and geometries. While the inlet temperature was previously optimized at 250°C in a previously validated assay, we systematically examined the temperature-dependent decarboxylation of tetrahydrocannabinolic acid-A (Δ9-THCA-A) and cyclization of CBD between 230°C and 310°C using different liners using favorable and unfavorable conditions. Significant differences in decarboxylation rate and CBD cyclization were observed between different liner types. While no temperature-dependent differences in decarboxylation rate were observed within liner type, liner-dependent differences were observed (α = 0.05), particularly between those with different geometry. In contrast, temperature and liner-dependent differences were observed for in situ formation of Δ9-THC (α = 0.05). This was influenced by liner geometry and to a smaller extent by surface deactivation. Effects were exacerbated with liner usage. While significant differences were observed using new and used GC liners, differences between liners of the same type but different lot numbers were not observed. Inter-instrument differences using the same liner were also evaluated and had minimal effect. Liner- and temperature-dependent effects were also confirmed using more than 20 cannabis plant extracts. Careful selection of liner, inlet conditions, and regular preventive maintenance can mitigate the risks associated with in situ formation Δ9-THC from CBD.
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Affiliation(s)
- Ya-Chih Cheng
- Department of Forensic Science, Sam Houston State University, Huntsville, Texas, USA
| | - Sarah Kerrigan
- Department of Forensic Science, Sam Houston State University, Huntsville, Texas, USA
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4
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Hart ED, Mullen L, Vikingsson S, Cone EJ, Winecker RE, Hayes ED, Flegel RR. Conversion of water-soluble CBD to ∆9-THC in synthetic gastric fluid-An unlikely cause of positive drug tests. J Anal Toxicol 2023; 47:632-635. [PMID: 37440360 DOI: 10.1093/jat/bkad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 07/15/2023] Open
Abstract
Cannabidiol (CBD) has been shown to convert to ∆9-tetrahydrocannabinol (∆9-THC) in acidic environments, raising a concern of conversion when exposed to gastric fluid after consumption. Using synthetic gastric fluid (SGF), it has been demonstrated that the conversion requires surfactants, such as sodium dodecyl sulfate (SDS), due to limited solubility of CBD. Recently, water-compatible nanoemulsions of CBD have been prepared as a means of fortifying beverages and water-based foods with CBD. Since these emulsions contain surfactants as part of their formulation, it is possible that these preparations might enhance the production of ∆9-THC even in the absence of added surfactants. Three THC-free CBD products, an oil, an anhydrous powder and a water-soluble formulation, were incubated for 3 h in SGF without SDS. The water-soluble CBD product produced a dispersion, while the powder and the oil did not mix with the SGF. No THC was detected with the CBD oil (<0.0006% conversion), and up to 0.063% and 0.0045% conversion to ∆9-THC was observed with the water-soluble CBD and the CBD powder, respectively. No formation of ∆8-THC was observed. In comparison, when the nano-formulated CBD was incubated in SGF with 1% SDS, 33-36% conversion to ∆9-THC was observed. Even though the rate of conversion with the water-soluble CBD was at least 100-fold higher compared to the CBD oil, it was still smaller than ∆9-THC levels reported in CBD products labeled "THC-free" or "<0.3% THC" based on the Agricultural Improvement Act of 2018 (the Farm Bill). Assuming a daily CBD dose of around 30 mg/day, it is unlikely that conversion of CBD to ∆9-THC could produce a positive urinary drug test for 11-Nor-9-carboxy-∆9-THC (15 ng/mL cut-off).
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Affiliation(s)
- E Dale Hart
- Center for Forensic Science Advancement and Application, RTI International, 3040 East Cornwallis Rd, Research Triangle Park, NC 27709, USA
| | - Lawrance Mullen
- Center for Forensic Science Advancement and Application, RTI International, 3040 East Cornwallis Rd, Research Triangle Park, NC 27709, USA
| | - Svante Vikingsson
- Center for Forensic Science Advancement and Application, RTI International, 3040 East Cornwallis Rd, Research Triangle Park, NC 27709, USA
| | - Edward J Cone
- Behavioral Pharmacology Research Unit, Johns Hopkins University School of Medicine, 5510 Nathan Shock Dr., Baltimore, MD 21224, USA
| | - Ruth E Winecker
- Center for Forensic Science Advancement and Application, RTI International, 3040 East Cornwallis Rd, Research Triangle Park, NC 27709, USA
| | - Eugene D Hayes
- Division of Workplace Programs, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857, USA
| | - Ronald R Flegel
- Division of Workplace Programs, Substance Abuse and Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857, USA
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Perini M, Gaggiotti A, Pianezze S, Ziller L, Larcher R. Stable Isotope Ratio Analysis for Authentication of Natural Antioxidant Cannabidiol (CBD) from Cannabis sativa. Antioxidants (Basel) 2023; 12:1421. [PMID: 37507959 PMCID: PMC10376380 DOI: 10.3390/antiox12071421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
Cannabidiol (CBD) is a non-psychoactive cannabinoid of Cannabis sativa that exhibits several beneficial pharmacological effects, including anti-inflammatory and antioxidant properties. The molecule can be obtained via extraction from the plant or through a biosynthetic route. The two products have both advantages and disadvantages, thus necessitating the development of methods capable of distinguishing between the two products. In this study, for the first time, the analysis of the stable isotope ratios of oxygen and hydrogen demonstrated high efficiency in the discrimination of CBD of a totally natural origin from that obtained through chemical synthesis. Considering a probability level of 95%, it was possible to identify threshold values for δ2H and δ18O of the totally natural CBD of -215‱ and +23.4‱, respectively. Higher values may indicate a non-entirely natural origin of CBD (i.e., a biosynthetic molecule).
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Affiliation(s)
- Matteo Perini
- Fondazione Edmund Mach, Via E. Mach 1, 38098 San Michele all'Adige, Italy
| | | | - Silvia Pianezze
- Fondazione Edmund Mach, Via E. Mach 1, 38098 San Michele all'Adige, Italy
| | - Luca Ziller
- Fondazione Edmund Mach, Via E. Mach 1, 38098 San Michele all'Adige, Italy
| | - Roberto Larcher
- Fondazione Edmund Mach, Via E. Mach 1, 38098 San Michele all'Adige, Italy
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6
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Gheasuddin Y, Galea GL. Cannabidiol impairs neural tube closure in mouse whole embryo culture. Birth Defects Res 2022; 114:1186-1193. [PMID: 35416425 PMCID: PMC9790336 DOI: 10.1002/bdr2.2013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/24/2022] [Accepted: 03/30/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Cannabidiol (CBD) is a nonpsychoactive constituent of cannabis widely available as a dietary supplement. Previous reports that it impairs the retinoid, sonic hedgehog, and folate metabolism pathways raise concern that it may impair closure of the embryonic neural tube (NT), producing NT defects including spina bifida and exencephaly. METHODS We undertook teratogenicity testing of CBD in mouse whole embryo culture. RESULTS At concentrations that do not diminish embryo viability, growth, or axial rotation, CBD dose-dependently impairs cranial NT closure, increasing the proportion of embryos that develop exencephaly. It concomitantly diminishes closure of the spinal NT, the posterior neuropore (PNP), producing longer neuropores at the end of culture which is a hallmark of spina bifida risk. Exposure to CBD does not disrupt the formation of long F-actin cables in surface ectoderm cells flanking the PNP or folding of the neuroepithelium at predictable hinge points. At the cellular level, CBD exposure does not alter proliferation or apoptosis of the spinal neuroepithelium. DISCUSSION Thus, CBD acts selectively as a neuroteratogen predisposing to spina bifida and exencephaly in mouse whole embryo culture at exposure levels not associated with overt toxicity. Large-scale testing of CBD's effects on NT closure, particularly in at-risk groups, is warranted to inform its marketing to women of childbearing age.
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Affiliation(s)
- Yosuf Gheasuddin
- Developmental Biology and CancerUCL GOS Institute of Child HealthLondonUK
| | - Gabriel L. Galea
- Developmental Biology and CancerUCL GOS Institute of Child HealthLondonUK
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7
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Casanova C, Ramier C, Fortin D, Carrieri P, Mancini J, Barré T. Cannabidiol use and perceptions in France: a national survey. BMC Public Health 2022; 22:1628. [PMID: 36038869 PMCID: PMC9421113 DOI: 10.1186/s12889-022-14057-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background Cannabidiol (CBD), a safe, non-intoxicating cannabis component, is growing in popularity in Europe and worldwide. However, CBD EU regulation is blurry, and consequent labelling and product quality issues may have implications for public health. There is therefore a need to assess the prevalence and perceived harmfulness of CBD use in EU countries, as well as to characterise CBD users. We aimed to do so in the French population. Methods In December 2021, an online survey was conducted in a sample respecting the French adult population structure for key demographic variables. Sociodemographic, behavioural and CBD perception data were collected. Three separate regressions were performed to identify correlates of i) having heard of CBD, ii) using CBD, iii) perceived harmfulness of CBD. A hierarchical classification was also performed to identify profiles of CBD users. Results The study sample comprised 1969 adults, of whom 69.2% had heard of CBD and 10.1% used it. Less than half (46.8%) of the former considered it harmful. Having heard of CBD was associated with younger age, being born in France, tobacco use, and cannabis use. CBD use was associated with younger age, tobacco use, cannabis use, poor self-reported general health status, and positive perception of alternative medicines. Cluster analysis revealed four different CBD user profiles based on socio-demographics and behavioural characteristics. Conclusion Ten percent of the adults in this French study used CBD, and several user profiles emerged. Our results indirectly advocate clearer European CBD regulations to ensure safe and high-quality products. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14057-0.
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Affiliation(s)
- Clémence Casanova
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France
| | - Clémence Ramier
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France
| | - Davide Fortin
- Sorbonne Economics Centre, University, Paris 1 Sorbonne, Paris, France
| | - Patrizia Carrieri
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France.
| | - Julien Mancini
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France.,Public Health Department, APHM, BIOSTIC, Marseille, France
| | - Tangui Barré
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de L'Information Médicale, ISSPAM, Marseille, France
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Turck D, Bohn T, Castenmiller J, De Henauw S, Hirsch‐Ernst KI, Maciuk A, Mangelsdorf I, McArdle HJ, Naska A, Pelaez C, Pentieva K, Siani A, Thies F, Tsabouri S, Vinceti M, Cubadda F, Frenzel T, Heinonen M, Marchelli R, Neuhäuser‐Berthold M, Poulsen M, Prieto Maradona M, Schlatter JR, Trezza V, van Loveren H, Albert O, Dumas C, Germini A, Gelbmann W, Kass G, Kouloura E, Noriega Fernandez E, Rossi A, Knutsen HK. Statement on safety of cannabidiol as a novel food: data gaps and uncertainties. EFSA J 2022; 20:e07322. [PMID: 35686177 PMCID: PMC9172591 DOI: 10.2903/j.efsa.2022.7322] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The European Commission has determined that cannabidiol (CBD) can be considered as a novel food (NF), and currently, 19 applications are under assessment at EFSA. While assessing these, it has become clear that there are knowledge gaps that need to be addressed before a conclusion on the safety of CBD can be reached. Consequently, EFSA has issued this statement, summarising the state of knowledge on the safety of CBD consumption and highlighting areas where more data are needed. Literature searches for both animal and human studies have been conducted to identify safety concerns. Many human studies have been carried out with Epidyolex®, a CBD drug authorised to treat refractory epilepsies. In the context of medical conditions, adverse effects are tolerated if the benefit outweighs the adverse effect. This is, however, not acceptable when considering CBD as a NF. Furthermore, most of the human data referred to in the CBD applications investigated the efficacy of Epidyolex (or CBD) at therapeutic doses. No NOAEL could be identified from these studies. Given the complexity and importance of CBD receptors and pathways, interactions need to be taken into account when considering CBD as a NF. The effects on drug metabolism need to be clarified. Toxicokinetics in different matrices, the half‐life and accumulation need to be examined. The effect of CBD on liver, gastrointestinal tract, endocrine system, nervous system and on psychological function needs to be clarified. Studies in animals show significant reproductive toxicity, and the extent to which this occurs in humans generally and in women of child‐bearing age specifically needs to be assessed. Considering the significant uncertainties and data gaps, the Panel concludes that the safety of CBD as a NF cannot currently be established.
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9
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Miller OS, Elder EJ, Jones KJ, Gidal BE. Analysis of cannabidiol (CBD) and THC in nonprescription consumer products: Implications for patients and practitioners. Epilepsy Behav 2022; 127:108514. [PMID: 34998268 DOI: 10.1016/j.yebeh.2021.108514] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/15/2021] [Accepted: 12/15/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE Cannabidiol products remains largely unregulated in the US. Unlike the Rx formulation of CBD [EpidiolexR], little information is available regarding labeling accuracy (does the product contain what the label says it does), lot to lot variability, nor long-term product stability. Understanding these properties are fundamental if these products are to be used in patients with epilepsy, where product variability of traditional AEDs has been suspected to result in inadequate seizure control. Therefore, we analyzed commercial CBD products, including oils, aqueous products (i.e., beverages), and various Other products for cannabinoid content vs label claims and stability under United States Pharmacopeia (USP) standards. METHOD Samples were diluted and analyzed by HPLC for CBD, THC, and CBN concentrations in order to assess product label accuracy. Products with <90% of label claim CBD were denoted over-labeled, products with >110% of label claim CBD were denoted under-labeled, and products between 90% and 110% of label claim CBD were denoted appropriately labeled, per USP standards. RESULTS Among commercial CBD Oils (n = 11), mean CBD concentration vs label claim was 91.56% [95% CI, 66.02-117.10%], although 18.18% of oils (n = 2) made nonspecific label claims of "hemp extract" in lieu of CBD. Among all oils, 36.36% (n = 4) were appropriately labeled, another 36.4% (n = 4) of all oils were under-labeled, maximum 128.3% label claim, and finally, 9.09% (n = 1) of oils were over-labeled. The remaining 18.18% (n = 2) of oils lacked specific CBD label claims, minimum of 0.3 mg CBD per 1-ml "dose". THC was detected in 54.55% (n = 6) of oils with a maximum concentration of 0.2% w/v and a minimum concentration of 0.036% w/v. Cannabinol was detectable in only 9.1% (n = 1) of products at a concentration of 0.00465% w/v. Among aqueous products (n = 21) tested, only 66.67% (n = 14) gave specific CBD label claims, with mean CBD concentration vs label claim of 59.93% [95% CI, 38.24-81.63%]. Only 7.14% (n = 1) of aqueous products with a label claim were appropriately labeled, 14.29% (n = 2) were found to be under-labeled, and 78.57% (n = 11) over-labeled. THC was detected in 23.81% (n = 5) of aqueous products tested with a maximum THC concentration of 0.0005% w/v, and a minimum concentration of 0.0002% w/v. Cannabinol was detected in 9.52% (n = 2) of aqueous products, both at a concentration of 0.0015% w/v. "Other" products (n = 7) tested ranged from chocolate bars to transdermal patches. Some 42.86% (n = 3) gave specific CBD label claims, with mean CBD concentration vs label claim of 67.01% [95% CI, 0.87-133.14%]. Among these three "Other" products with specific label claims, 33% (n = 1) was appropriately labeled, and 66.67% (n = 2) were over-labeled, with CBD concentrations vs label claim ranging from a minimum of 39.30% to a maximum of 101.99%. The remaining 57.14% (n = 5) of "Other" products tested made nonspecific CBD label claims, denoting CBD content in terms of "full spectrum hemp extract" or "activated cannabinoids". One such product was labeled with a "40-50-mg CBD" range instead of a single, specific value. Tetrahydrocannabinol was detected in 71.43% (n = 5) of Other products tested with a maximum concentration of 0.0046% w/w, and a minimum concentration of 0.0008% w/w. Cannabinol was detected in 14.3% (n = 1) of Other products at a concentration of 0.0001% w/w. CONCLUSION We demonstrate that commercial CBD products, especially aqueous beverages, can show inconsistent labeling, vary largely from their label claims should they make them, and show lot-to-lot variability making dosing unpredictable.
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Affiliation(s)
- Owen S Miller
- University of Wisconsin, School of Pharmacy, 777 Highland Ave, Madison, WI 53705, United States.
| | - Edmund J Elder
- University of Wisconsin, School of Pharmacy, 777 Highland Ave, Madison, WI 53705, United States; University of Wisconsin - Zeeh Pharmaceutical Experiment Station, 777 Highland Ave, Madison, WI 53705-2222, United States.
| | - Karen J Jones
- University of Wisconsin - Zeeh Pharmaceutical Experiment Station, 777 Highland Ave, Madison, WI 53705-2222, United States.
| | - Barry E Gidal
- University of Wisconsin, School of Pharmacy, 777 Highland Ave, Madison, WI 53705, United States.
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10
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Kirkland AE, Fadus MC, Gruber SA, Gray KM, Wilens TE, Squeglia LM. A scoping review of the use of cannabidiol in psychiatric disorders. Psychiatry Res 2022; 308:114347. [PMID: 34952255 PMCID: PMC8799523 DOI: 10.1016/j.psychres.2021.114347] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 02/08/2023]
Abstract
Cannabidiol (CBD) has become a fast-growing avenue for research in psychiatry, and clinicians are challenged with understanding the implications of CBD for treating mental health disorders. The goal of this review is to serve as a guide for mental health professionals by providing an overview of CBD and a synthesis the current evidence within major psychiatric disorders. PubMed and PsycINFO were searched for articles containing the terms "cannabidiol" in addition to major psychiatric disorders and symptoms, yielding 2952 articles. Only randomized controlled trials or within-subject studies investigating CBD as a treatment option for psychiatric disorders (N = 16) were included in the review. Studies were reviewed for psychotic disorders (n = 6), anxiety disorders (n = 3), substance use disorders (tobacco n = 3, cannabis n = 2, opioid n = 1), and insomnia (n = 1). There were no published studies that met inclusion criteria for alcohol or stimulant use disorder, PTSD, ADHD, autism spectrum disorder, or mood disorders. Synthesis of the CBD literature indicates it is generally safe and well tolerated. The most promising preliminary findings are related to the use of CBD in psychotic symptoms and anxiety. There is currently not enough high-quality evidence to suggest the clinical use of CBD for any psychiatric disorder.
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Affiliation(s)
- Anna E Kirkland
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States.
| | - Matthew C Fadus
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Staci A Gruber
- Cognitive and Clinical Neuroimaging Core, Marijuana Investigations for Neuroscientific Discovery (MIND) Program, McLean Hospital, Boston, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Kevin M Gray
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Timothy E Wilens
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Center for Addiction Medicine Co-Director, Massachusetts General Hospital, Boston, MA, United States
| | - Lindsay M Squeglia
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
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11
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Bedrin MD, Putko RM, Dickens JF. Analgesia in Athletes: A Review of Commonly Used Oral and Injectable Modalities. Sports Med Arthrosc Rev 2021; 29:e71-e76. [PMID: 34730120 DOI: 10.1097/jsa.0000000000000325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pain is common among athletes at all levels and the treatment of pain can be a challenging and frustrating task. The team physician needs a fundamental knowledge of analgesic strategies as it relates to athletes. It is important to understand the mechanism of action, side effect profile/associated complications, incidence of and indications for use, as well as the controversies associated with the most common analgesic medications used in sports medicine. Several "in vogue" treatment modalities, including cannabidiol, are also becoming more commonly used and are worth discussion.
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12
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Fortin D, Di Beo V, Massin S, Bisiou Y, Carrieri P, Barré T. Reasons for using cannabidiol: a cross-sectional study of French cannabidiol users. J Cannabis Res 2021; 3:46. [PMID: 34615556 PMCID: PMC8495963 DOI: 10.1186/s42238-021-00102-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/06/2021] [Indexed: 11/22/2022] Open
Abstract
Background Cannabidiol and cannabidiol-based products are proliferating in many countries. This recent and rapid diffusion prompts investigating the reasons for its use. Methods We analyzed data from an online survey among cannabidiol users in the French general population (n = 1166) selected for their interest in such products. We described the reported reasons for using cannabidiol. We performed logistic regressions to identify the correlates of declaring well-being and other specific reasons for using cannabidiol. We also provided descriptive data regarding the cannabidiol patterns of use. Results Well-being was the most cited primary reason for use (27% of the sample). Declaring well-being as a primary reason for using cannabidiol was inversely associated with cigarette smoking, cannabis use, and employment. Among cannabidiol users reporting well-being as their primary reason for use, stress and sleep improvements were the most-cited specific reasons. In the whole study sample, the most common modes of use were smoking cannabidiol-rich cannabis (61%) and ingesting cannabidiol oil sublingually (19%). Conclusions In a sample of cannabidiol users from France, well-being was the most-cited primary reason for use, and smoking was the first route of administration. Further research is needed to clarify to what extent expected effects are scientifically sound and to understand country-related specificities regarding patterns of use.
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Affiliation(s)
| | - Vincent Di Beo
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
| | - Sophie Massin
- Univ. Artois, CNRS, IESEG School of management, Univ. Lille, UMR 9221, Lille Economie Management (LEM), F-62000, Arras, France
| | - Yann Bisiou
- University Paul Valéry Montpellier 3, CORHIS , Montpellier, France
| | - Patrizia Carrieri
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France
| | - Tangui Barré
- Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Marseille, France.
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13
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Knezevic F, Nikolai A, Marchart R, Sosa S, Tubaro A, Novak J. Residues of herbal hemp leaf teas – How much of the cannabinoids remain? Food Control 2021. [DOI: 10.1016/j.foodcont.2021.108146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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14
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Vodovar D, Caré W, Dufayet L, Batisse A. Cannabidiol-induced toxicity: who is the culprit? Am J Emerg Med 2021; 47:284-285. [PMID: 34112527 DOI: 10.1016/j.ajem.2021.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/02/2021] [Indexed: 12/21/2022] Open
Affiliation(s)
- Dominique Vodovar
- Centre Antipoison de Paris, Hôpital Fernand Widal - Fédération de Toxicologie de l'AP-HP, Paris 75010, France; Inserm UMRS-1144, Faculté de Pharmacie, Paris 75006, France; UFR de médecine, Université de Paris, Paris 75010, France.
| | - Weniko Caré
- Centre Antipoison de Paris, Hôpital Fernand Widal - Fédération de Toxicologie de l'AP-HP, Paris 75010, France; Inserm UMRS-1144, Faculté de Pharmacie, Paris 75006, France; Service de médecine interne, Hôpital d'instruction des armées Bégin, Saint-Mandé 94160, France
| | - Laurène Dufayet
- Centre Antipoison de Paris, Hôpital Fernand Widal - Fédération de Toxicologie de l'AP-HP, Paris 75010, France; Inserm UMRS-1144, Faculté de Pharmacie, Paris 75006, France; UFR de médecine, Université de Paris, Paris 75010, France; Unité Médico-Judiciaire, Hôpital Hôtel-Dieu - AP-HP, Paris 75004, France
| | - Anne Batisse
- Centre d'addictovigilance de Paris, Hôpital Fernand Widal - AP-HP, Paris 75010, France
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15
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Abstract
Modafinil is a wakefulness-promoting agent that is known to be used off-label as a cognitive enhancer and for the treatment of attention deficit hyperactivity disorder (ADHD).1 There are increasing case reports of Modafinil-induced psychosis; however, this is the first to report a patient with ADHD to develop psychosis from Modafinil use.
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16
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Carrubba AR, Ebbert JO, Spaulding AC, DeStephano D, DeStephano CC. Use of Cannabis for Self-Management of Chronic Pelvic Pain. J Womens Health (Larchmt) 2020; 30:1344-1351. [PMID: 33252316 DOI: 10.1089/jwh.2020.8737] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Chronic pelvic pain (CPP) affects up to 15% of women in the United States. The endocannabinoid system is a potential pharmacological target for pelvic pain as cannabinoid receptors are highly expressed in the uterus and other nonreproductive tissues. We hypothesize that cannabis use is common for self-management of CPP, and our primary objective was to determine the prevalence of cannabis use in this population. Materials and Methods: A cross-sectional survey of women with pelvic and perineal pain, dyspareunia, or endometriosis was performed between March and August 2019. Subjects were recruited in an outpatient gynecology office. An anonymous, confidential, electronic survey was performed using a tablet. Statistical analysis was performed using JMP (SAS, Cary, NC). Results: A total of 240 patients were approached, with 113 responses (47.1% response rate). There were 26 patients who used cannabis (23%). The majority used at least once per week (n = 18, 72%). Most users (n = 24, 96%) reported improvement in symptoms, including pain, cramping, muscle spasms, anxiety, depression, sleep disturbances, libido, and irritability. Over one-third (35%) stated that cannabis use decreased the number of phone calls or messages sent to their provider, and 39% reported decreased number of clinical visits. Side effects, including dry mouth, sleepiness, and feeling "high," were reported by 84% (n = 21). Conclusions: Almost one-quarter of patients with CPP report regular use of cannabis as an adjunct to their prescribed therapy. Although side effects are common, most users report improvement in symptoms. Our study highlights the potential of cannabis as a therapeutic option for patients with CPP.
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Affiliation(s)
- Aakriti R Carrubba
- Department of Gynecologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Jon O Ebbert
- Department of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida, USA
| | - David DeStephano
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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17
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McGregor IS, Cairns EA, Abelev S, Cohen R, Henderson M, Couch D, Arnold JC, Gauld N. Access to cannabidiol without a prescription: A cross-country comparison and analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 85:102935. [DOI: 10.1016/j.drugpo.2020.102935] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 01/03/2023]
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18
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Cannabidiol im Kontext erstmaliger verkehrsmedizinischer Fahreignungsabklärungen in der Schweiz. Rechtsmedizin (Berl) 2020. [DOI: 10.1007/s00194-020-00419-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Zusammenfassung
Einleitung
Cannabidiol (CBD) ist neben Tetrahydrocannabinol (THC) ein bedeutender Bestandteil der Cannabis-Pflanze (C. sativa und C. indica). Dem CBD selbst wird keine bedeutsame psychoaktive Wirkung zugeschrieben und es wird nicht zu den Betäubungsmitteln gezählt; klinisch sind aber sedierende/entspannende Effekte bestätigt. Seit dem Jahr 2014 sind in der Schweiz CBD-haltige Tabakersatzprodukte mit einem THC-Gehalt <1 % frei verkäuflich.
Fragestellung
Es ist unklar, ob und bei welchen Konzentrationen CBD einen Einfluss auf die Fahrfähigkeit (FF) und Fahreignung (FE) hat. Bei Konsum von Tabakersatzprodukten mit einem THC-Gehalt <1 % kann der Blutgrenzwert für THC (in der Schweiz: 1,5 µg/l) überschritten werden, was automatisch zu gesetzlicher Fahrunfähigkeit führt. In der vorliegenden Studie wurde der Stellenwert von CBD bei erstmaligen verkehrsmedizinischen Fahreignungsabklärungen von Cannabiskonsumenten untersucht.
Methode
Retrospektive stichwortbasierte Recherche und Analyse der Datenbank der Abteilung Verkehrsmedizin des Instituts für Rechtsmedizin der Universität Zürich. Deskriptive statistische Analyse. Einschlusskriterien: abgeschlossene verkehrsmedizinische Gutachten im Administrativverfahren aufgrund von erstmaligem Fahren unter Cannabiseinfluss (Fahren unter Drogeneinfluss, FuD). Ausschluss von Konsum sonstiger Betäubungsmittel. Untersuchungszeitpunkt zwischen 01.01.2016 und 31.12.2019. Analyse nach Alter, Geschlecht und Beurteilungsentscheid.
Resultat
Im untersuchten Zeitraum insgesamt 62.997 Fälle, davon 1082 Erst-FuD unter Cannabinoiden. Keine Fälle vor 01.01.2016, jedoch dann stetige Zunahme, bis 15,17 % aller Cannabis-Begutachtungen im Jahr 2019. (Bei‑)Konsum von CBD: 62 Fälle (5,7 %). Die meisten CBD-Konsumenten sind männlich (91,9 %). Unterschiedliche Altersverteilung zwischen CBD und THC-Konsumenten mit auffälliger Häufung bei 30- bis 40-jährigen Exploranden. Kaum Unterschiede in der Beurteilung der Fahreignung.
Schlussfolgerung
Cannabidiol spielt in dieser Untersuchung zwar eine untergeordnete, jedoch zunehmende Rolle bei der Begutachtung erstmaligen Fahrens unter Cannabiseinfluss. Ein Einfluss von CBD auf die FF ist daraus somit nicht ableitbar und ergibt sich auch nicht aus anderen publizierten Untersuchungen. Aus Sicht der Autoren bedarf es klinisch-prospektiver Forschungsprojekte zur Klärung der Wirkung von CBD unter Berücksichtigung von subjektiver Fahrfähigkeitswahrnehmung und Fahrleistungsdefiziten.
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Montoya Z, Conroy M, Vanden Heuvel BD, Pauli CS, Park SH. Cannabis Contaminants Limit Pharmacological Use of Cannabidiol. Front Pharmacol 2020; 11:571832. [PMID: 33013414 PMCID: PMC7516211 DOI: 10.3389/fphar.2020.571832] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/25/2020] [Indexed: 01/15/2023] Open
Abstract
For nearly a century, Cannabis has been stigmatized and criminalized across the globe, but in recent years, there has been a growing interest in Cannabis due to the therapeutic potential of phytocannabinoids. With this emerging interest in Cannabis, concerns have arisen about the possible contaminations of hemp with pesticides, heavy metals, microbial pathogens, and carcinogenic compounds during the cultivation, manufacturing, and packaging processes. This is of particular concern for those turning to Cannabis for medicinal purposes, especially those with compromised immune systems. This review aims to provide types of contaminants and examples of Cannabis contamination using case studies that elucidate the medical consequences consumers risk when using adulterated Cannabis products. Thus, it is imperative to develop universal standards for cultivation and testing of products to protect those who consume Cannabis.
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Affiliation(s)
- Zackary Montoya
- Institute of Cannabis Research, Colorado State University-Pueblo, Pueblo, CO, United States
| | - Matthieu Conroy
- Institute of Cannabis Research, Colorado State University-Pueblo, Pueblo, CO, United States
| | | | - Christopher S Pauli
- Institute of Cannabis Research, Colorado State University-Pueblo, Pueblo, CO, United States
| | - Sang-Hyuck Park
- Institute of Cannabis Research, Colorado State University-Pueblo, Pueblo, CO, United States
- Department of Biology, Colorado State University-Pueblo, Pueblo, CO, United States
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20
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Choi NG, Marti CN, DiNitto DM, Baker SD. Cannabis and synthetic cannabinoid poison control center cases among adults aged 50+, 2009–2019. Clin Toxicol (Phila) 2020; 59:334-342. [DOI: 10.1080/15563650.2020.1806296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Namkee G. Choi
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
| | - C. Nathan Marti
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
| | - Diana M. DiNitto
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, TX, USA
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21
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Cannabis and Canabidinoids on the Inflammatory Bowel Diseases: Going Beyond Misuse. Int J Mol Sci 2020; 21:ijms21082940. [PMID: 32331305 PMCID: PMC7215817 DOI: 10.3390/ijms21082940] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/07/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023] Open
Abstract
Inflammatory bowel diseases (IBD) are characterized by a chronic and recurrent gastrointestinal condition, including mainly ulcerative colitis (UC) and Crohn’s disease (CD). Cannabis sativa (CS) is widely used for medicinal, recreational, and religious purposes. The most studied compound of CS is tetrahydrocannabinol (THC) and cannabidiol (CBD). Besides many relevant therapeutic roles such as anti-inflammatory and antioxidant properties, there is still much controversy about the consumption of this plant since the misuse can lead to serious health problems. Because of these reasons, the aim of this review is to investigate the effects of CS on the treatment of UC and CD. The literature search was performed in PubMed/Medline, PMC, EMBASE, and Cochrane databases. The use of CS leads to the improvement of UC and CD scores and quality of life. The medical use of CS is on the rise. Although the literature shows relevant antioxidant and anti-inflammatory effects that could improve UC and CD scores, it is still not possible to establish a treatment criterion since the studies have no standardization regarding the variety and part of the plant that is used, route of administration and doses. Therefore, we suggest caution in the use of CS in the therapeutic approach of IBD until clinical trials with standardization and a relevant number of patients are performed.
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22
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Kiselak TD, Koerber R, Verbeck GF. Synthetic route sourcing of illicit at home cannabidiol (CBD) isomerization to psychoactive cannabinoids using ion mobility-coupled-LC–MS/MS. Forensic Sci Int 2020; 308:110173. [DOI: 10.1016/j.forsciint.2020.110173] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/10/2020] [Accepted: 01/27/2020] [Indexed: 01/22/2023]
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Lachenmeier DW, Diel P. A Warning against the Negligent Use of Cannabidiol in Professional and Amateur Athletes. Sports (Basel) 2019; 7:E251. [PMID: 31847307 PMCID: PMC6956040 DOI: 10.3390/sports7120251] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/11/2019] [Accepted: 12/12/2019] [Indexed: 12/20/2022] Open
Abstract
Cannabidiol (CBD) is a non-psychoactive cannabinoid, widely marketed to athletes for claimed effects such as decreased anxiety, fear memory extinction, anti-inflammatory properties, relief of pain and for post-exercise recovery. The World Anti-Doping Agency (WADA) has excluded CBD from its list of prohibited substances. Nevertheless, caution is currently advised for athletes intending to use the compound-except CBD, all other cannabinoids are still on the prohibited list. CBD products, specifically non-medicinal, so-called full-spectrum cannabis extracts, may contain significant levels of these substances, but also contaminations of tetrahydrocannabinol (THC) (>2.5 mg/day in >30% of products on the German market) potentially leading to positive doping tests. Labelled claims about CBD content and absence of THC are often false and misleading. Contaminations with the psychoactive THC can result in adverse effects on cognition and, in general, the safety profile of CBD with respect to its toxicity is a controversial topic of discussion. For these reasons, we would currently advise against the use of over-the-counter CBD products, especially those from dubious internet sources without quality control.
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Affiliation(s)
- Dirk W. Lachenmeier
- Chemisches und Veterinäruntersuchungsamt (CVUA) Karlsruhe, Weissenburger Strasse 3, 76187 Karlsruhe, Germany
| | - Patrick Diel
- Institute for Cardiovascular Research and Sports Medicine, Department of Molecular and Cellular Sports Medicine, German Sports University, 50333 Cologne, Germany;
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