Be Prepared to Discuss CBD Products With Patients

The rising legalization, acceptance, and availability of marijuana (cannabis) receives the lion’s share of attention in public health circles, but the past few years have also seen a marketing surge in cannabis-derived cannabidiol (CBD) products. CBD—one of the two principal chemicals in marijuana—is believed to be benign and potentially valuable pharmacologically since it does not produce a high like tetrahydrocannabinol (THC)—the other active ingredient in marijuana.

The research into the biology, medical benefits, and risks of CBD has not kept up with the commercial proliferation of this product. And that has left physicians, including psychiatrists, feeling ill prepared to discuss CBD with their patients, said Smita Das, M.D., Ph.D., M.P.H., an assistant professor of psychiatry and behavioral health sciences at Stanford University and a member of APA’s Council on Addiction Psychiatry.

“These products are readily available in chain drugstores across the country or online, and patients are talking about them,” Das said. She explained that she’s had several patients who are in treatment for opioid use disorder ask about CBD’s pain-relief properties and whether CBD is a safer alternative to cannabis. The answer to that question and other psychiatric benefits of CBD remain unknown.

“Some small clinical studies have suggested CBD could be beneficial for anxiety and schizophrenia, but these findings are still preliminary,” she noted.

The Food and Drug Administration (FDA) in 2018 approved a concentrated form of CBD for the treatment of two rare forms of childhood epilepsy, but that is the only medical indication to date.

While pure-grade CBD used in research studies has been shown to be safe, that is not always the case with commercial CBD products, noted Yasmin Hurd, M.D., a professor of psychiatry and neuroscience at the Icahn School of Medicine at Mount Sinai, in a JAMA Psychiatry editorial published in January. “Pesticide, mold, lead, and other adulterants including even synthetic cannabinoids, which induce marked psychosis, have been detected in [CBD sold in commercial] products,” she wrote.

Even if a CBD-containing product is safe, it may not meet FDA guidelines. FDA rules prohibit the active ingredients of medications from being included in or marketed as foods or dietary supplements. Cosmetic products with CBD can be sold, but these products cannot make any unproven health claims. Many companies flaunt these rules, and in November 2019, the FDA sent out a warning to 15 companies for illegally marketing CBD products against their guidelines.

“Wherever CBD is presented as a health benefit, we must ensure that existing rules and regulations are followed,” Hurd wrote. Das noted that while it is possible for physicians to prescribe purified CBD off label to patients who are currently taking over-the-counter CBD products to prevent them from ingesting adulterated products, the CBD medication (marketed as Epidiolex) costs about $30,000 a year.

“In many places, marijuana products are actually cheaper than CBD products,” Das said. “I have had patients transition to marijuana because the CBD product became cost-prohibitive, as well as others who were curious to try marijuana because CBD was working for their condition.” Such increased use of marijuana can come with increased risks, she noted, including cannabis use disorder or psychosis.

When Das is approached by patients about the possibility of using CBD to reduce psychiatric symptoms, she said that she first discusses with them alternative medications that have been approved for their conditions. “We should not be afraid to have these conversations with patients and ask them openly about all the substances and chemicals they are taking or have taken,” she continued.

She noted that APA’s Council on Addiction is working on some guidance documents for psychiatrists to help with these discussions. The American Academy of Addiction Psychiatry and American Academy of Child and Adolescent Psychiatry also have some cannabis and CBD-related resources available on their websites. ■