Trends in Internet Searches for Cannabidiol (CBD) in the United States

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).

Cannabidiol as an Adjunctive Treatment for Acute Bipolar Depression: A Pilot Study: Le cannabidiol comme traitement d'appoint de la dépression bipolaire aiguë : une étude pilote

OBJECTIVE

The treatment of bipolar depression remains challenging due to the limited effective and safe therapeutic options available; thus, developing newer treatments that are effective and well tolerable is an urgent unmet need. The objective of the present trial was to test 150 to 300 mg/day of cannabidiol as an adjunctive treatment for bipolar depression.

METHOD

A randomized, double-blind, placebo-controlled pilot study to assess the efficacy of adjunctive cannabidiol in bipolar depression was used. Efficacy parameters were changes in the Montgomery-Åsberg Depression Rating Scale (MADRS) from baseline to week 8. Secondary outcomes included response and remission rates, changes in anxiety and psychotic symptoms, and changes in functioning. Patients continued double-blind treatment until week 12 to monitor for adverse effects, laboratory analysis, and manic symptoms. Study registry: NCT03310593.

RESULTS

A total of 35 participants were included. MADRS scores significantly decreased from baseline to the endpoint (placebo, -14.56; cannabidiol, -15.38), but there was no significant difference between the groups. Similarly, there were no other significant effects on the secondary outcomes. However, an exploratory analysis showed a significant effect of cannabidiol 300 mg/day in reducing MADRS scores from week 2 to week 8 (placebo, -6.64; cannabidiol, -13.72). There were no significant differences in the development of manic symptoms or any other adverse effects.

CONCLUSION

Cannabidiol did not show significantly higher adverse effects than placebo. Despite the negative finding on the primary outcome, an exploratory analysis suggested that cannabidiol should be further studied in bipolar depression in higher doses of at least 300 mg/day and under research designs that could better control for high placebo response.

Perceptions of Orthopaedic Sports Medicine Surgeons About Medical Cannabidiol Use: A Survey Study

INTRODUCTION

Multiple studies exist identifying cannabidiol (CBD) as an effective part of an orthopaedic patient's pain regimen; however, there is a paucity of studies elucidating orthopaedic surgeons' perception of the use and prescription of CBD in the medical setting. This study surveys orthopaedic sports medicine surgeons about their previous education on and current perceptions and usage of CBD in their medical practice.

METHODS

Between April 2023 and July 2023, orthopaedic sports medicine surgeons from across the country were surveyed. This survey was designed in hopes of identifying physician perceptions and current use of CBD as well as their previous education and training on its use.

RESULTS

Overall, 75 orthopaedic surgeons responded. More than three-fourths of responders had not received formal education on medical CBD use, nor did they have partners or colleagues who used CBD in their practice. More than half of all surgeons believed that there is a stigma associated with CBD use. A higher proportion of surgeons from CBD legal states recommended CBD to help patients control their pain (53.7% vs. 37.5%). Less than 15% of responders believed that CBD can adversely affect surgical outcomes. Finally, four-fifths of all responders believed that CBD is easy to legally access and affordable to buy by patients who desire it.

DISCUSSION

The relative novelty of CBD inclusion in medicine has led to a lack of early education and overall experience with its use among orthopaedic sports medicine surgeons. Still, surgeons believe that CBD is a safe and effective option to control pain. As surgeons continue to gain more familiarity and trust with CBD's medical uses over time, it has the potential to be a mainstay in orthopaedic multimodal pain regimens.

Physician Perceptions of Cannabidiol (CBD) and Cannabis in Sports Medicine and Performance

Objectives

There is growing evidence regarding cannabinoid use in sports medicine and performance, especially cannabidiol (CBD). This study aims to determine if sports medicine physicians are recommending cannabinoids for therapeutic purposes, as well as analyze perceptions of cannabinoids within sports medicine and performance.

Methods

Physician members of the American Medical Society for Sports Medicine (AMSSM) completed an anonymous survey on demographics, CBD and Cannabis recommendations, as well as attitudes toward cannabinoid products within sports medicine. Factors associated with CBD and cannabis recommendations as well as perceptual differences were found using multivariate regression modelling.

Results

Responses from 333 physicians were recorded. The following groups were less likely to agree with allowing cannabis for recreational purposes: female gender (coeff. = 0.79 (0.33-1.25), p=0.001), increasing age (coeff. = 0.04 (0.02, 0.07), p  <  0.001), and rural respondents (compared to baseline urban, coeff. = 1.16 (0.36, 1.95), p=0.004). Similarly, these three factors were associated with a higher likelihood of disagreeing with WADA removing cannabis from the prohibited substance list and with the NCAA allowing CBD use by collegiate athletes (p ≤ 0.045). CBD was less likely to be recommended by pediatricians, rural physicians, and academic physicians (p ≤ 0.030). Male physicians and younger physicians were less likely to identify cannabis as performance-enhancing (p ≤ 0.042).

Conclusions

Sports medicine physicians have varying views on cannabinoids. While sports medicine physicians generally have favorable attitudes toward CBD and cannabis, these perceptions appear to be significantly affected by age, practice type, and gender.

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.

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.

Consumer perception, knowledge, and uses of cannabidiol

Introduction

The legalization of cannabidiol (CBD) across the United States, in varying degrees, has made CBD easily accessible to consumers for complementary and medical purposes. However, there is a paucity of scientific evidence on the benefits and risks of commercially available CBD. In the literature, 2 studies have gathered consumer perceptions and attitudes on cannabis products, specifically CBD, using survey-based questionnaires. This study aimed to build on the aforementioned studies in obtaining consumer perception and knowledge of CBD products using a national survey-based questionnaire.

Methods

Respondents were recruited through an anonymous, nationwide, online survey administered through Qualtrics in the United States from March 28 to April 30, 2021. The survey consisted of demographics, perceived efficacy and safety of CBD, and resources to obtain CBD information. The survey responses were reported using descriptive statistics along with median and interquartile range for the Likert portion.

Results

A total of 1158 respondents accessed the survey. The median age was 43 and 50% of respondents were female. The uses for CBD included neurological disorders, pulmonary conditions, gastrointestinal disorders, and chronic pain. The most commonly reported safety concern related to taking CBD was anxiety. Participants agreed that CBD is safe when used responsibly for medical use, and social media was the main source used to obtain information about CBD.

Discussion

Respondents who used CBD for a condition thought it was helpful; however, most of the adverse effects were rated as moderate to severe, requiring medical attention from a health care professional, hospital, or emergency room visit.

Cannabis use among workers with work-related injuries and illnesses: results from a cross-sectional study of workers' compensation claimants in Ontario, Canada

OBJECTIVES

Little is known about how workers use cannabis following a work-related injury/illness, including whether they receive clinical guidance. The objective was to compare characteristics of workers using and not using cannabis after a work-related injury/illness and describe use patterns.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Workers who experienced a work-related physical injury/illness resulting in one or more days of lost time compensated by the workers' compensation authority in Ontario, Canada (n=1196).

METHODS

Participants were interviewed 18 or 36 months after their injury/illness. Participants were asked about their past-year cannabis use, including whether use was for the treatment of their work-related condition. Sociodemographic, work and health characteristics were compared across cannabis groups: no past-year use; use for the work-related condition; use unrelated to the work-related condition. Cannabis use reasons, patterns, perceived impact and healthcare provider engagement were described.

RESULTS

In total, 27.4% of the sample reported using cannabis (14.1% for their work-related condition). Workers using cannabis for their condition were less likely to be working (58.0%) and more likely to have quite a bit/extreme pain interference (48.5%), psychological distress (26.0%) and sleep problems most/all the time (62.1%) compared with those not using cannabis (74.3%, 26.3%, 12.0% and 38.0%, respectively) and those using cannabis for other reasons (74.2%, 19.5%, 12.0% and 37.1%, respectively) (all p<0.0001). No significant differences were observed in medical authorisations for use among those using cannabis for their condition (20.4%) or unrelated to their condition (15.7%) (p=0.3021). Healthcare provider guidance was more common among those using cannabis for their condition (32.7%) compared with those using for other reasons (17.1%) (p=0.0024); however, two-thirds of this group did not receive guidance.

CONCLUSIONS

Cannabis may be used to manage the consequences of work-related injuries/illnesses, yet most do not receive clinical guidance. It is important that healthcare providers speak with injured workers about their cannabis use.

Absence of Age Verification for Online Purchases of Cannabidiol and Delta-8: Implications for Youth Access

PURPOSE

This study assessed the age verification process for purchasing and shipping cannabidiol (CBD) and Delta-8 tetrahydrocannabinol products from online retailers.

METHODS

We purchased CBD and Delta-8 products online from 20 brick-and-mortar shops located in the United States that sold products online and shipped products to consumers. We documented online age verifications at the time of purchase and whether identification or a signature was required at delivery.

RESULTS

37.5% of the CBD and 70.0% of the Delta-8 websites required the customer to confirm their age (18 + or 21+ years). Age verification or contact with the customer was not requested at the point of home delivery for all products.

DISCUSSION

Methods for age verification at time of purchase are self-reported and easily circumvented. Policies and policy enforcement are needed to prevent youth access to CBD and Delta-8 products from online sources.

Cannabidiol and cannabis-inspired terpene blends have acute prosocial effects in the BTBR mouse model of autism spectrum disorder

Introduction

Cannabidiol (CBD) is a non-intoxicating phytocannabinoid with increasing popularity due to its purported therapeutic efficacy for numerous off-label conditions including anxiety and autism spectrum disorder (ASD). Those with ASD are commonly deficient in endogenous cannabinoid signaling and GABAergic tone. CBD has a complex pharmacodynamic profile that includes enhancing GABA and endocannabinoid signaling. Thus, there is mechanistic justification for investigating CBD's potential to improve social interaction and related symptoms in ASD. Recent clinical trials in children with ASD support CBD's beneficial effects in numerous comorbid symptoms, but its impact on social behavior is understudied.

Methods

Here, we tested the prosocial and general anxiolytic efficacy of a commercially available CBD-rich broad spectrum hemp oil delivered by repeated puff vaporization and consumed via passive inhalation in the female cohort of the BTBR strain, a common inbred mouse line for preclinical assessment of ASD-like behaviors.

Results

We observed that CBD enhanced prosocial behaviors using the 3-Chamber Test with a different vapor dose-response relationship between prosocial behavior and anxiety-related behavior on the elevated plus maze. We also identified that inhalation of a vaporized terpene blend from the popular OG Kush cannabis strain increased prosocial behavior independently of CBD and acted together with CBD to promote a robust prosocial effect. We observed similar prosocial effects with two additional cannabis terpene blends from the Do-Si-Dos and Blue Dream strains, and further reveal that these prosocial benefits rely on the combination of multiple terpenes that comprise the blends.

Discussion

Our results illustrate the added benefit of cannabis terpene blends for CBD-based treatment of ASD.

Using Social Media Data to Investigate Public Perceptions of Cannabis as a Medicine: Narrative Review

BACKGROUND

The use and acceptance of medicinal cannabis is on the rise across the globe. To support the interests of public health, evidence relating to its use, effects, and safety is required to match this community demand. Web-based user-generated data are often used by researchers and public health organizations for the investigation of consumer perceptions, market forces, population behaviors, and for pharmacoepidemiology.

OBJECTIVE

In this review, we aimed to summarize the findings of studies that have used user-generated text as a data source to study medicinal cannabis or the use of cannabis as medicine. Our objectives were to categorize the insights provided by social media research on cannabis as medicine and describe the role of social media for consumers using medicinal cannabis.

METHODS

The inclusion criteria for this review were primary research studies and reviews that reported on the analysis of web-based user-generated content on cannabis as medicine. The MEDLINE, Scopus, Web of Science, and Embase databases were searched from January 1974 to April 2022.

RESULTS

We examined 42 studies published in English and found that consumers value their ability to exchange experiences on the web and tend to rely on web-based information sources. Cannabis discussions have portrayed the substance as a safe and natural medicine to help with many health conditions including cancer, sleep disorders, chronic pain, opioid use disorders, headaches, asthma, bowel disease, anxiety, depression, and posttraumatic stress disorder. These discussions provide a rich resource for researchers to investigate medicinal cannabis-related consumer sentiment and experiences, including the opportunity to monitor cannabis effects and adverse events, given the anecdotal and often biased nature of the information is properly accounted for.

CONCLUSIONS

The extensive web-based presence of the cannabis industry coupled with the conversational nature of social media discourse results in rich but potentially biased information that is often not well-supported by scientific evidence. This review summarizes what social media is saying about the medicinal use of cannabis and discusses the challenges faced by health governance agencies and professionals to make use of web-based resources to both learn from medicinal cannabis users and provide factual, timely, and reliable evidence-based health information to consumers.

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.

Social media discourse and internet search queries on cannabis as a medicine: A systematic scoping review

The use of cannabis for medicinal purposes has increased globally over the past decade since patient access to medicinal cannabis has been legislated across jurisdictions in Europe, the United Kingdom, the United States, Canada, and Australia. Yet, evidence relating to the effect of medical cannabis on the management of symptoms for a suite of conditions is only just emerging. Although there is considerable engagement from many stakeholders to add to the evidence base through randomized controlled trials, many gaps in the literature remain. Data from real-world and patient reported sources can provide opportunities to address this evidence deficit. This real-world data can be captured from a variety of sources such as found in routinely collected health care and health services records that include but are not limited to patient generated data from medical, administrative and claims data, patient reported data from surveys, wearable trackers, patient registries, and social media. In this systematic scoping review, we seek to understand the utility of online user generated text into the use of cannabis as a medicine. In this scoping review, we aimed to systematically search published literature to examine the extent, range, and nature of research that utilises user-generated content to examine to cannabis as a medicine. The objective of this methodological review is to synthesise primary research that uses social media discourse and internet search engine queries to answer the following questions: (i) In what way, is online user-generated text used as a data source in the investigation of cannabis as a medicine? (ii) What are the aims, data sources, methods, and research themes of studies using online user-generated text to discuss the medicinal use of cannabis. We conducted a manual search of primary research studies which used online user-generated text as a data source using the MEDLINE, Embase, Web of Science, and Scopus databases in October 2022. Editorials, letters, commentaries, surveys, protocols, and book chapters were excluded from the review. Forty-two studies were included in this review, twenty-two studies used manually labelled data, four studies used existing meta-data (Google trends/geo-location data), two studies used data that was manually coded using crowdsourcing services, and two used automated coding supplied by a social media analytics company, fifteen used computational methods for annotating data. Our review reflects a growing interest in the use of user-generated content for public health surveillance. It also demonstrates the need for the development of a systematic approach for evaluating the quality of social media studies and highlights the utility of automatic processing and computational methods (machine learning technologies) for large social media datasets. This systematic scoping review has shown that user-generated content as a data source for studying cannabis as a medicine provides another means to understand how cannabis is perceived and used in the community. As such, it provides another potential 'tool' with which to engage in pharmacovigilance of, not only cannabis as a medicine, but also other novel therapeutics as they enter the market.

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.

CBD Retailers in NC Promote CBD Online to Treat Pain Violating FDA Rules About Medical Claims and Offer Low-CBD/High-Price Products

Introduction

Cannabidiol (CBD) products are available nearly nationwide in the US and can coexist with medical or recreational programs. North Carolina (NC) is an example of a state with a program dedicated to integrating hemp cultivation and medicinal CBD exclusively, containing a multitude of retailers selling it as a primary product. The Food and Drug Administration (FDA) mandates that non-FDA approved CBD products cannot be marketed using medical or health-related claims and has sent warning letters to retailers violating these terms. We aim to characterize the online content of the NC CBD market by analyzing retailers' websites to determine whether hemp/CBD shops comply with FDA regulations in terms of medical claims and analyze the claimed CBD content and price of products offered online.

Methods

We randomly selected three CBD retailers from the ten most populated cities of NC. We analyzed their website content: product type, medical claims, other disclaimers, price, and CBD content.

Results

We found that edible, oral, inhalable, and topical products are offered in similar proportions. Word analysis of product description revealed that "pain" and "pain relief" were the most common medical claim, followed by inflammation and anxiety. Health claims were mostly related to wellbeing. Other attributes indicate that products are associated with pleasant flavors or sensations (ie, cool, lavender, delicious, honey, menthol), which resembles the strategies used for tobacco advertisement. Most products (61%) claimed to contain less than 1000 mg of CBD. The median price of products ranged from $15-30 per 300 mg. We found a positive correlation between CBD content and price.

Discussion

Our data demonstrate that the NC online CBD market does not comply with FDA regulations, primarily targets patients with pain, inflammation, or anxiety, and offers products with low CBD concentration and high prices. New policies should limit the access and online promotion of non-pharmaceutical grade CBD products.

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.

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.

Complementary and Alternative Medicine (CAM) use in Children with Epilepsy

Complementary and alternative medicine (CAM) use by the pediatric population with epilepsy in rural Pennsylvania was studied to characterize the prevalence, perceived effectiveness, and reasons for CAM use. This study additionally assessed the adequacy of parent-physician communication regarding CAM usage. A telephone survey was administered to 200 parents/caregivers of children with epilepsy followed at Hershey Medical Center. Thirteen percent of respondents indicated CAM use by their child. Common types of CAM used were cannabis-related products such as CBD oil and medical marijuana. Forty-eight percent of CAM users chose to initiate CAM owing to dissatisfaction with the outcomes of antiseizure drugs. Fifty-nine percent noticed a decrease in seizure frequency with CAM use, and more than 11% of CAM users reported side effects from CAM. Eighty percent of CAM users had discussions regarding CAM with their child's neurologist. CAM use was found to be associated with increased seizure severity (P = .004) and the prior use of cannabidiol (Epidiolex) (P < .001) or the ketogenic diet (P = .001). Increased seizure severity and the prior use of Epidiolex or the ketogenic diet may be used as predictors for the identification of patients with a higher likelihood of using CAM. Interest in future CAM use, especially cannabis-related products, was expressed in a large percentage of non-CAM users. Given the high parental or caregiver interest in CAM, providers are encouraged to be proactive in initiating discussions about CAM and collaborate with parents/caregivers to ensure the safe usage of CAM among pediatric patients.

The Impact of Recent Tobacco Regulations and COVID-19 Restrictions and Implications for Future E-Cigarette Retail: Perspectives from Vape and Vape-and-Smoke Shop Merchants

BACKGROUND

Tobacco regulations and COVID-19 state orders have substantially impacted vape retail. This study assessed vape retailers' perspectives regarding regulations and future retail activities.

METHODS

In March-June 2021, 60 owners or managers of vape or vape-and-smoke shops (n = 34 vs. n = 26) in six US metropolitan areas completed an online survey assessing: (1) current and future promotional strategies and product offerings; and (2) experiences with federal minimum legal sales age (T21) policies, the federal flavored e-cigarette ban, and COVID-19-related orders. Quantitative data were analyzed descriptively; qualitative responses to open-ended questions were thematically analyzed.

RESULTS

Most participants had websites (65.0%), used social media for promotion (71.7%), offered curbside pickup (51.7%), and sold CBD (e.g., 73.3% vape products, 80.0% other); many also sold other tobacco products. Knowledge varied regarding state/local policies in effect before federal policies. Participants perceived tobacco regulations and COVID-19 orders as somewhat easy to understand/implement and perceived noncompliance consequences as somewhat severe. Qualitative themes indicated concerns regarding regulations' negative impacts (e.g., sales/customer loss, customers switching to combustibles), insufficient evidence base, challenges explaining regulations to customers, and concerns about future regulatory actions.

CONCLUSIONS

Surveillance of tobacco retail, consumer behavior, and regulatory compliance is warranted as policies regarding nicotine and cannabis continue evolving.

Public interest in ∆8-Tetrahydrocannabinol (delta-8-THC) increased in US states that restricted ∆9-Tetrahydrocannabinol (delta-9-THC) use

BACKGROUND

There is an expanding unregulated market for a psychotropic compound called ∆8-Tetrahydrocannabinol (delta-8-THC) that is being derived from hemp, but there are no empirical estimates of public interest in this compound.

METHODS

To measure public interest, we obtained yearly Google query fractions (QFs) that mentioned delta-8-THC (i.e., "delta 8," "delta-8," or "Δ8") for the past decade (from January 2011 through August 2021) for every country and territory in the world and every state in the United States (US) from Google Trends. We also obtained the same trends for the last complete month of data for all US states (July 2021) to compare across cannabis use policies. We summarized QFs across years, countries, US states and cannabis policies in US states using linear regression, means and ratios. We estimated raw search counts for the US using comscore.com.

RESULTS

The global rate of delta-8-THC searches was stable between 2011 and 2019 before increasing by 257.0% from 2019 to 2020 and 705.0% from 2020 to 2021. In 2021, the rate of delta-8-THC searches in the US was at least 10 times higher than the rates in other countries or territories. In absolute terms, there were 22.3 million delta-8-THC searches in the US in the first 8 months of 2021 alone. Increases in delta-8-THC searches from 2020 to 2021 occurred in all 50 US states and the District of Columbia (Mean 854.2%; range = 256.4% - 2831.2%) but continued to vary substantially between states in 2021. In July 2021, the legal status of delta-9-THC use across US states explained 49.0% of the variance in delta-8-THC QFs between US states (R2 = 0.490; p < 0.001) and was inversely associated, where delta-8-THC QFs were higher in jurisdictions with stricter cannabis use policies.

CONCLUSION

Public interest in delta-8-THC increased rapidly in 2020 and 2021 and was particularly high in US states that restricted delta-9-THC use. Jurisdictions should clarify whether delta-8-THC can be sold as a hemp product.

"I got a bunch of weed to help me through the withdrawals": Naturalistic cannabis use reported in online opioid and opioid recovery community discussion forums

A growing body of research has reported on the potential opioid-sparing effects of cannabis and cannabinoids, but less is known about specific mechanisms. The present research examines cannabis-related posts in two large online communities on the Reddit platform (“subreddits”) to compare mentions of naturalistic cannabis use by persons self-identifying as actively using opioids versus persons in recovery. We extracted all posts mentioning cannabis-related keywords (e.g., “weed”, “cannabis”, “marijuana”) from December 2015 through August 2019 from an opioid use subreddit and an opioid recovery subreddit. To investigate how cannabis is discussed at-scale, we identified and compared the most frequent phrases in cannabis-related posts in each subreddit using term-frequency-inverse document frequency (TF-IDF) weighting. To contextualize these findings, we also conducted a qualitative content analysis of 200 random posts (100 from each subreddit). Cannabis-related posts were about twice as prevalent in the recovery subreddit (n = 908; 5.4% of 16,791 posts) than in the active opioid use subreddit (n = 4,224; 2.6% of 159,994 posts, p < .001). The most frequent phrases from the recovery subreddit referred to time without using opioids and the possibility of using cannabis as a “treatment.” The most frequent phrases from the opioid subreddit referred to concurrent use of cannabis and opioids. The most common motivations for using cannabis were to manage opioid withdrawal symptoms in the recovery subreddit, often in conjunction with anti-anxiety and GI-distress “comfort meds,” and to enhance the “high” when used in combination with opioids in the opioid subreddit. Despite limitations in generalizability from pseudonymous online posts, this examination of reports of naturalistic cannabis use in relation to opioid use identified withdrawal symptom management as a common motivation. Future research is warranted with more structured assessments that examines the role of cannabis and cannabinoids in addressing both somatic and affective symptoms of opioid withdrawal.

Cannabidiol Product Dosing and Decision-Making in a National Survey of Individuals with Fibromyalgia

Many people with fibromyalgia use cannabidiol (CBD) products despite limited rigorous evidence of benefit. In the current study, we conducted a secondary analysis of a cross-sectional survey of N = 878 people with fibromyalgia to investigate naturalistic decision making around CBD product choices, use patterns, and dosing. We subgrouped participants based on use of high-THC cannabis (HTC) in the past year (yes/no) as previous studies have shown that HTC use influences CBD use patterns. The study population was largely female (93.6%), white (91.5%) and 55.5 years old on average. Participants typically purchased CBD products online or at dispensaries, with purchasing driven by personal research (63%) rather than endorsement from medical professionals (16%). Overall, tinctures and topicals were the most common administration routes endorsed. However, participants in the past-year HTC group used inhalation routes far more frequently than those who did not (39.8% vs 7.1%). Among participants using CBD tinctures or edibles, the average dose per session was 16 mg and 24 to 27 mg per day, although approximately one-third of participants did not know what dose of CBD they used. Participants using both inhalation and non-inhalation administration routes reported greater symptom relief than those using non-inhalation routes alone. However, there was no consistent relationship between CBD dose and reported effects, possibly due to expectancy effects around CBD products or interindividual variability. Our granular investigation reveals variability of CBD product dosing practices for fibromyalgia, and how past-year HTC use influences CBD product use. Future clinical trials should investigate the potential benefits of low-dose (<50mg) botanical CBD products. PERSPECTIVE: This article shows that past-year HTC use strongly influences how people with fibromyalgia choose and use CBD products. Participants typically used <50 mg/d of CBD, and there was no relationship between higher CBD dose and reported therapeutic benefit. Future clinical trials should investigate therapeutic benefits of low dose CBD.

Recreational Cannabidiol: Awareness, Prevalence of use, and Associated Factors in a Representative Sample of the German Population

BACKGROUND

Recreational cannabidiol (CBD) is frequently promoted as a medicinal or therapeutic cannabis product worldwide. Nationwide population-based data on awareness and use of recreational CBD are currently lacking.

OBJECTIVE

This study estimates the prevalence of recreational CBD awareness and use among the population in Germany. It also explores potential associations with socio-demographic characteristics, tobacco smoking, and e-cigarette use.

METHODS

We used data from a cross-sectional household survey (German Study on Tobacco Use, DEBRA) fielded across two waves in October-November 2020 and February-March 2021. Data were collected using computer-assisted face-to-face interviews among participants aged ≥14 years (n = 4026). Outcome variables were CBD awareness (yes/no) and CBD ever use (yes/no). The sample was weighted to ensure representativeness of the prevalence estimates. Associations with socio-demographic variables, tobacco smoking, and e-cigarette use were assessed using multivariable logistic regression.

RESULTS

Approximately half of the population in Germany (48.3%, 95% CI: 46.8-49.9) was aware of recreational CBD products, and 4.3% (95% CI: 3.7-5.0) had ever used them (including 1.1% current users). Awareness was associated with younger age, higher education levels, female sex, living in urban regions, no migration background, tobacco smoking, and e-cigarette use. Ever use was associated with higher education levels, living in urban regions, tobacco smoking, and e-cigarette use.

CONCLUSIONS

Awareness of recreational CBD products is high but ever use is currently low in Germany. Given the uncertain legal framework regarding the marketing of recreational CBD products, the changing retail landscape, and potential harms of CBD use, structured monitoring is warranted for public health purposes.

Enhancing Endocannabinoid Control of Stress with Cannabidiol

The stress response is a well-defined physiological function activated frequently by life events. However, sometimes the stress response can be inappropriate, excessive, or prolonged; in which case, it can hinder rather than help in coping with the stressor, impair normal functioning, and increase the risk of somatic and mental health disorders. There is a need for a more effective and safe pharmacological treatment that can dampen maladaptive stress responses. The endocannabinoid system is one of the main regulators of the stress response. A basal endocannabinoid tone inhibits the stress response, modulation of this tone permits/curtails an active stress response, and chronic deficiency in the endocannabinoid tone is associated with the pathological complications of chronic stress. Cannabidiol is a safe exogenous cannabinoid enhancer of the endocannabinoid system that could be a useful treatment for stress. There have been seven double-blind placebo controlled clinical trials of CBD for stress on a combined total of 232 participants and one partially controlled study on 120 participants. All showed that CBD was effective in significantly reducing the stress response and was non-inferior to pharmaceutical comparators, when included. The clinical trial results are supported by the established mechanisms of action of CBD (including increased N-arachidonylethanolamine levels) and extensive real-world and preclinical evidence of the effectiveness of CBD for treating stress.

Therapeutic Claims in Cannabidiol (CBD) Marketing Messages on Twitter

Although the U.S. FDA has only approved exactly one cannabidiol (CBD) drug product (specifically to treat seizures), CBD products are proliferating rapidly through different modes of usage including food products, cosmetics, vaping pods, and supplements (typically, oils). Despite the FDA clearly warning consumers about unproven health claims made by manufacturers selling CBD products over the counter, the CBD market share was nearly 3 billion USD in 2020 and is expected to top 55 billion USD in 2028. In this context, it is important to assess the presence of health claims being made on social media, especially claims that are part of marketing messages. To this end, we collected over two million English tweets discussing CBD themes. We created a hand-labeled dataset and built machine learned classifiers to identify marketing tweets from regular tweets that may be generated by consumers. The best classifier achieved 85% precision, 83% recall, and 84% F-score. Our analyses showed that pain, anxiety disorders, sleep disorders, and stress are the four main therapeutic claims made constituting 31.67%, 27.11%, 13.77%, and 10.37% of all medical claims made on Twitter, respectively. Also, more than 93% of advertised CBD products are edibles or oil/tinctures. Our effort is the first to demonstrate the feasibility of surveillance of marketing claims for CBD products. We believe this could pave way for more explorations into this indispensable task in the current landscape of social media driven health (mis)information and communication.

Effects of Marijuana Use in Patients with Orthopaedic Trauma

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The use of cannabis and cannabis-related products has increased dramatically in the last 2 decades. As states continue to legalize cannabis products, it is important for surgeons to understand the effects they may have on patients who have sustained orthopaedic trauma.

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Cannabinoids have been shown to decrease the severity of certain symptoms related to traumatic brain injury as well as posttraumatic stress disorder.

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Cannabinoids can modulate the body's endocannabinoid system, which can play an important role in bone homeostasis. Activation of cannabinoid receptors has been shown to be bone-protective in adults.

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Venous thromboembolism is a major concern for trauma patients. Cannabis use has been linked to overall increased rates of venous thromboembolism events.

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Literature regarding human-based cannabis studies is sparse; however, the growing field is opening new opportunities for research of this topic.

Superlatives in news articles reporting non-FDA approved indications for use of cannabis and cannabis products with a focus on psychiatric disorders: a cross-sectional analysis

The exaggerated language used in news articles to describe the benefits of cannabis for conditions without FDA indications may mislead the public and healthcare providers. Thus, this study's objective was to investigate the use of exaggerated language in news articles focused on cannabis and cannabis-derived products. Using a cross-sectional study design, we searched Google News from March 3, 2020, and September 3, 2019 for 11 prespecified superlative terms along with the search terms "cannabis," "cannabidiol," "pot," "marijuana," "weed," and "CBD." Articles were evaluated for these exaggerative terms describing cannabis and cannabis-derived products along with additional news article characteristics. Screening and data extraction occurred in a masked, duplicate fashion. We identified 612 superlative terms in 374 different news articles focused on cannabis and cannabis-derived products from 262 news outlets. Only 26 (of 374, 7.0%) news articles provided clinical data. In total, superlative terms were used to describe cannabis and cannabis-derived products for the treatment of 91 medical conditions, of which only 2 are FDA approved. The most common psychiatric disorder indicated was anxiety disorder appearing in 88 news articles. Superlatives in news articles covering the treatment of psychiatric illnesses with cannabis and cannabis-derived products are common.

Acute objective and subjective intoxication effects of legal-market high potency THC-dominant versus CBD-dominant cannabis concentrates

As the market for cannabis concentrate products grows, the lack of research regarding the effects of concentrated THC and CBD becomes more glaring. The present study analyzes cannabinoid blood levels and subjective outcomes of physical sensation and affective state after ad libitum use of legal-market concentrate products. Recreational cannabis users were randomly assigned to THC- or CBD-dominant concentrate products, completing a baseline session, and an experimental mobile laboratory session consisting of timepoints before, immediately after, and one-hour after concentrate use. THC-dominant concentrates induced higher intoxication, and higher ratings of drug effect and drug liking than the CBD-dominant concentrate. Both products induced immediate feelings of elation, diminishing over the subsequent hour. Subjective outcomes in the CBD-dominant group revealed immediate decreases in tension and anxiety relative to pre-use, while the THC-dominant group only saw significant decreases in anxiety after one hour. Paranoia spiked immediately post-use in THC-dominant concentrate users, returning to baseline within an hour. Overall, the CBD-dominant concentrate invoked positive mood effects, lower intoxication and an absence of undesirable effects experienced with the THC-dominant concentrate, potentially mitigating negative effects when combined. Results support the need for further investigation into harm-reduction potential of concentrated CBD when used alone and with THC.

Cannabinoid Use Among Liver Transplant Recipients

The effect of cannabinoids on liver transplant outcomes is an area of active research. We aimed to investigate marijuana (MJ) and cannabidiol (CBD) use among liver transplant recipients at the University of Colorado Hospital (UCH), specifically prevalence, habits, and predictors of use. Liver transplant recipients followed at UCH with valid email addresses were sent an informed consent postcard and survey invitation. This exploratory survey was conducted using REDCap. IBM SPSS Statistics software was used for statistical analysis. Of 1227 recipients who were sent surveys, 538 people responded. On average, respondents were 59 years old, with 63.7% male and 81.7% White. Hepatitis C virus (HCV; 30.4%) and alcohol use (17.7%) were the most common etiologies of liver disease. Among respondents, 23.8% reported current MJ use. Methods of use included smoking (72.4%), ingestion (55.3%), and vaporization (31.7%). Top reasons for MJ use were recreation (56.5%), anxiety (54.8%), and pain (53.2%). Among respondents, 21.0% currently used CBD, usually in the form of creams or lotions (58.9%) and to relieve pain (84.9%) and anxiety (31.1%). In multivariable analysis, age (odds ratio [OR], 0.941; 95% confidence interval [CI], 0.923-0.959; P < 0.001), diabetes mellitus (OR, 0.357; 95% CI, 0.171-0.746; P = 0.01), HCV cirrhosis (OR, 3.949; 95% CI, 2.281-6.835; P < 0.001), alcohol-related cirrhosis (OR, 2.101; 95% CI, 1.202-3.671; P = 0.01), and current tobacco use (OR, 2.918; 95% CI, 1.065-7.990; P = 0.04) were significant predictors of MJ use. Our study shows that cannabinoid use after liver transplant is common. MJ use is associated with decreasing age, alcohol-related and HCV cirrhosis, and tobacco use. Anxiety, pain, and recreation were top reasons for its use. Transplant teams should address reasons why their patients use MJ and CBD and develop programs to mitigate anxiety and pain after transplant. Further studies are needed to examine effects of cannabinoids on liver transplant outcomes.

Comparison of CBD and Cannabis Use Motives

Cannabidiol, also known as CBD, has increasingly gained popularity as a cure-all product and is now found in products across a variety of industries. Despite the surge in popularity, little remains known about individual motives and patterns of CBD use. The goal of this study was to gain a better understanding of the similarities and differences between motives for CBD and cannabis use as well as comparing motives for younger and older users. Participants (N= 171) in U.S. states and territories with legalized cannabis for recreational use were recruited via Amazon MTurk and were asked to complete an anonymous survey assessing their CBD and cannabis use, effects, and motives for use. The greatest differences between self-reported CBD and cannabis use were for side effect profiles. While the recreational use motive was more commonly endorsed for cannabis, use for beauty purposes was more common for CBD. No age group differences emerged for motives to use CBD or cannabis. Future research examining age-related differences in a larger, more age-diverse samples is recommended.

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.

Potential Role of Cannabidiol on Sports Recovery: A Narrative Review

The use of cannabidiol (CBD) among athletes is becoming extensive and frequent. This could be due to the elimination of CBD from the list of prohibited substances by federations and international institutions of sport. The legalization and resulting production, and commercialization of CBD, could increase its intake in sports professionals. This commercialization of cannabinoids has fueled a race to study their properties, benefits, and risks for health and performance in athletes. Although there is evidence that suggests some beneficial properties such as anxiolytics, antidepressants, anti-inflammatory, and antioxidants among others, the evidence presented so far is neither clear nor conclusive. There are significant gaps in knowledge of the physiological pathways that explain the role of CBD in sports performance. This mini-review examines evidence suggesting that CBD has the potential to be used as a part of the strategies to recover from fatigue and muscle damage related to physical and cognitive exertion in sports.

Circumvention of COVID-19-related restrictions on tobacco sales by the e-cigarette industry in South Africa and comparative analyses of heated tobacco product vs combustible cigarette volume sales during 2018-2020

As a public health measure against COVID-19, South Africa restricted the sale of "tobacco, e-cigarettes and related products" for 5 months, ending on August 17, 2020. We examined marketing activities related to novel tobacco products (e-cigarettes and heated tobacco products) during this restriction. Using web scraping, we accessed data for 2661 e-cigarette liquids marketed online by South African vendors in June 2020. We also analyzed heated tobacco product volume sales (kits) using retail scanner data from Nielsen Company. The 2661 e-cigarette liquids assessed online comprised cannabidiol liquids, 28.8%[767/2661], nicotine salts, 10.4%[276/2661], e-cigarette juice concentrates, 14.1%[376/2661], nicotine-free e-liquid, 4.0%[107/2661], and nicotine-containing e-liquid, 42.6%[1135/2661]. Cannabidiol liquids had the highest percentage of fruit (78.4%[601/767]) and tobacco flavors (9.4%[72/767]). During the restriction, many online e-cigarette vendors actively promoted cannabidiol liquid in lieu of regular e-liquid. Nielsen retail scanner data showed that volume of heated tobacco product sales in February 2020, preceding the restriction (7.76 million kits), were higher than in February 2019 (4.52 million kits). The restriction saw decreased sales of heated tobacco products; mean weekly heated tobacco product sales in the 6 weeks following the restriction (772,585 kits/week) were dramatically lower versus the 6 weeks preceding the restriction (2.26 million kits/week). Lifting the restriction saw a 131% spike in sales between the latter half of August 2020 (825,638 kits) and mid-September 2020 sales (1.90 million kits), even though total sales in September 2020 were half of what was observed in the preceding year (3.81 million units in September 2020, vs 6.33 million units, September 2019). The marketing of cannabidiol and other novel products by e-cigarette manufacturers and the tobacco industry may encourage youth use; close monitoring is required.

Availability and Promotion of Cannabidiol (CBD) Products in Online Vape Shops

Vaping products containing cannabidiol (CBD), a cannabis-derived compound used in wellness products and available in all 50 US states, were recently implicated in outbreaks of poisonings. Little is known about the commercial availability of CBD products in vape shops (i.e., stores that sell e-cigarettes). To document the availability and marketing of CBD products in online vape shops, in June 2020, we used the Google Chrome browser without cached data to collect the first two pages of search results generated by five Google queries (n = 100 search results) indicative of shopping for vaping products (e.g., "order vapes"). We then determined whether and what type of CBD products could be mail-ordered from the returned websites, and whether any explicit health claims were made about CBD. Over a third of the search results (n = 37; 37.0%) directed to vape shops that allowed visitors to also mail-order CBD. These shops sold 12 distinct categories of CBD products-some with direct analogs of tobacco or cannabis products including CBD cigarettes, edibles, flowers, pre-rolled joints, and vapes. Two vape shops made explicit health claims of the therapeutic benefits of CBD use, including in the treatment of anxiety, inflammation, pain, and stress. The abundance and placement of CBD in online vape shops suggests a growing demand and appeal for CBD products among e-cigarette users. Additional surveillance on the epidemiology of CBD use and its co-use with tobacco is warranted.

The Cannabinoids Tetrahydrocannabinol, Cannabinol, Cannabidiol, Tetrahydrocannabivarin, and 11-nor-9-carboxy-∆9-THC in Hair

The cannabinoids tetrahydrocannabinol (THC), tetrahydrocannabivarin (THCV), cannabidiol (CBD), cannabinol (CBN) and (-)-11-nor-9-carboxy-∆9-tetrahydrocannabinol (THC-COOH) were determined in 4773 hair samples. Confirmation of THC-COOH was by GC-MS/MS. Confirmation of THC, THCV, CBN and CBD was by LC-MS/MS on an AB Sciex QTRAP 6500+ LC-MS/MS. The purpose of this work was not to utilize any analyte other than THC-COOH as indicative of ingestion, but to assess the absence or presence, and relative concentrations, of the other cannabinoid analytes in hair of marijuana users vs. primarily cannabidiol users. In this regard, ten percent of samples contained significantly higher concentrations of CBD relative to THC than the other 90%. A concentration of CBD that is five times greater than that of THC was proposed as good evidence of primarily CBD ingestion.THC concentrations in the samples ranged from < LOD (5 pg/mg) to 47,808 pg/mg hair, varying widely in the relationship between parent THC and the metabolite THC-COOH. CBN was present in most samples, but concentrations relative to THC decreased with increasing THC concentrations. Only 26% of the samples contained THCV detectable by the method. When present, THCV concentrations averaged 1.77% of THC. A limitation of the study is the lack of subject histories to determine types and amounts of products used and mode of ingestion. Also, not all THC from external contamination may have been removed. Nonetheless, the data provide a useful guide as to what cannabinoids may be found in hair, at what concentrations, under conditions of marijuana vs. likely primarily CBD use.

Internet Interest in Colon Cancer Following the Death of Chadwick Boseman: Infoveillance Study

Background

Compared with White Americans, Black Americans have higher colon cancer mortality rates but lower up-to-date screening rates. Chadwick Boseman was a prominent Black American actor who died of colon cancer on August 28, 2020. As announcements of celebrity diagnoses often result in increased awareness, Boseman’s death may have resulted in greater interest in colon cancer on the internet, particularly among Black Americans.

Objective

This study aims to quantify the impact of Chadwick Boseman’s death on web-based search interest in colon cancer and determine whether there was an increase in interest in regions of the United States with a greater proportion of Black Americans.

Methods

We conducted an infoveillance study using Google Trends (GT) and Wikipedia pageview analysis. Using an autoregressive integrated moving average algorithm, we forecasted the weekly relative search volume (RSV) for GT search topics and terms related to colon cancer that would have been expected had his death not occurred and compared it with observed RSV data. This analysis was also conducted for the number of page views on the Wikipedia page for colorectal cancer. We then delineated GT RSV data for the term colon cancer for states and metropolitan areas in the United States and determined how the RSV values for these regions correlated with the percentage of Black Americans in that region. Differences in these correlations before and after Boseman’s death were compared to determine whether there was a shift in the racial demographics of the individuals conducting the searches.

Results

The observed RSVs for the topics colorectal cancer and colon cancer screening increased by 598% and 707%, respectively, and were on average 121% (95% CI 72%-193%) and 256% (95% CI 35%-814%) greater than expected during the first 3 months following Boseman’s death. Daily Wikipedia page view volume during the 2 months following Boseman’s death was on average 1979% (95% CI 1375%-2894%) greater than expected, and it was estimated that this represented 547,354 (95% CI 497,708-585,167) excess Wikipedia page views. Before Boseman’s death, there were negative correlations between the percentage of Black Americans living in a state or metropolitan area and the RSV for colon cancer in that area (r=−0.18 and r=−0.05, respectively). However, in the 2 weeks following his death, there were positive correlations between the RSV for colon cancer and the percentage of Black Americans per state and per metropolitan area (r=0.73 and r=0.33, respectively). These changes persisted for 4 months and were all statistically significant (P<.001).

Conclusions

There was a significant increase in web-based activity related to colon cancer following Chadwick Boseman’s death, particularly in areas with a higher proportion of Black Americans. This reflects a heightened public awareness that can be leveraged to further educate the public.

Epidemiology of cannabidiol related cases reported in the National Poison Data System - 2019-2020

INTRODUCTION

Cannabidiol (CBD) has become a popular supplement in consumer products in recent years, resulting in part from normalization of the cultivation of low THC cannabis in 2018. However, the actual content of CBD-labeled products is frequently uncertain, as oversight of such products is minimal. To date, there is little pragmatic knowledge regarding exposures to products labeled as containing CBD.

METHODS

Cases reported to Poison Control Centers from April 1, 2019 and March 31, 2020, the first year in which CBD was identified uniquely as a substance in the National Poison Data System, were analyzed for demographic, temporal, and clinical trends.

RESULTS

Poison Control Centers handled 1581 cases exposures to CBD-containing products between April 1, 2019 and March 31, 2020. There was a significant trend of over 5 additional cases related to this substance per month (linear regression coefficient = 5.2, 95% CI: 1.52-8.98). Patients under age 13 years made up 44.0% of reported exposures. Mild CNS depression (10.3%), tachycardia (5.7%), dizziness/vertigo (5.3%), vomiting (4.9%), nausea (4.5%), and agitation (4.4%) were the most frequently reported symptoms. 13% of cases were coded as having "moderate" or "severe" medical outcomes. There were no fatalities.

CONCLUSIONS

Cases reported to Poison Control Centers regarding exposures to CBD-labeled products have been increasing, representing an emerging trend of interest to Poison Control Center professionals, clinicians, and public health officials. Further monitoring of this trend is recommended.

Cannabidiol (CBD) and other drug use among young adults who use cannabis in Los Angeles

INTRODUCTION

Cannabidiol (CBD) is purportedly a promising therapeutic agent to provide relief for a variety of medical conditions with mild or no psychoactive effects. However, little is known about young adults who use cannabis and CBD-dominant products, and associations between CBD use and other drug use.

METHODS

Young adults (aged 24-32) who currently used cannabis (n = 239) were surveyed in Los Angeles in March 2019 through March 2020. The sample was divided into CBD-dominant (at least 1:1 CBD:THC ratio) and THC-dominant product users. We described CBD forms, reasons and conditions for CBD use and examined between-group differences in sociodemographic characteristics, cannabis practices, health and other drug use.

RESULTS

CBD-dominant users were more likely to be female, use cannabis at lower frequency and amount (except for edible/drinkable/oral products), self-report medical motivation for cannabis use, use cannabis for pain and report more health problems. Oil, flower, topicals and sprays/drops/tinctures were the most prevalent CBD forms. Psychological problems and pain were commonly reported conditions and medical reasons for CBD use. CBD-dominant users were more likely to report illicit drug use, where psilocybin use was markedly different between the two groups.

CONCLUSIONS

CBD use was associated with health histories and motivations linked to pain and psychological problems. Positive association between CBD use and illicit drug use may indicate self-medication for psychological conditions. Future studies should evaluate the effectiveness of various CBD forms and dose regimens for treatment of pain and psychological problems, and as a potential intervention for decreasing other drug use and associated harms.

Evidence for Use of Cannabinoids in Mood Disorders, Anxiety Disorders, and PTSD: A Systematic Review

OBJECTIVE

Two primary compounds of the cannabis plant (Cannabis sativa), delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), differentially and dose-dependently affect mood and anxiety. In this systematic review, the authors summarize the design and results of controlled trials assessing the effects of THC and CBD on affective disorders, anxiety disorders, and posttraumatic stress disorder (PTSD).

METHODS

A keyword search of eight online literature databases identified eight randomized controlled trials of defined CBD or THC doses for the target populations.

RESULTS

A 1-month trial of daily THC (up to 3 mg per day) for DSM-II anxiety disorder reduced anxiety symptoms, but symptoms were very low throughout the study. Another trial of sequential, single-day, low-dose THC in social anxiety disorder found no symptom changes. Two studies reported that single-dose CBD pretreatment reduced anxiety in laboratory paradigms among individuals with social anxiety disorder. A study of daily CBD for 4 weeks among adolescents with social anxiety disorder indicated modest symptom improvements. One crossover trial involving 10 patients with PTSD showed that THC added to standard pharmacotherapy reduced self-reported nightmares. Two small studies of THC for hospitalized patients with unipolar or bipolar depression found no improvement of depression; instead, anxiety and psychotic symptoms emerged in >50% of patients.

CONCLUSIONS

With only eight very small studies, insufficient evidence was found for efficacy of CBD and THC to manage affective disorders, anxiety disorders, or PTSD. Therefore, medical cannabis should not be recommended for treating patients with these disorders. Further research should investigate the safety and efficacy of managing psychiatric disorders with cannabinoids.

Homegrown perceptions about the medical use and potential abuse of CBD and THC

Despite heightened consumer interest in cannabinoids such as cannabidiol (CBD) and tetrahydrocannabinol (THC), little is known about public perceptions regarding their medical use and potential for abuse, particularly relative to commonly used medications. Using data from 1,050 U.S. adult respondents from a national survey conducted in 2019, this study found that more than half of respondents perceived CBD, THC, hemp, and marijuana as having medical use. They also perceived the potential for abuse of CBD, THC, hemp, and marijuana as significantly less than potential for abuse of commonly prescribed anti-anxiety and pain medications. At the nexus of medical use and potential abuse, public perceptions classified CBD and hemp as similar to over-the-counter pain relief medications such as Advil and Tylenol and did not classify marijuana as a Schedule I substance. Slightly more than 20% of respondents reported having consumed CBD and/or THC. CBD was consumed more than THC to reduce pain while THC was consumed more than CBD for recreation. There were no differences in the types of medications they were replacing with CBD and THC.

Assessment of hemp oil-based cannabidiol use in a community-based pharmacy setting

BACKGROUND

The Agricultural Improvement Act of 2018 legalized the commercial use of hemp-based products, including cannabidiol (CBD). However, the U.S. Food and Drug Administration (FDA) does not currently regulate the commercial sale of hemp oil-based CBD, and there is no FDA-approved indication for its nonprescription formulations despite the growing demand for, and use of, hemp oil-based CBD.

OBJECTIVES

Characterize the use of hemp oil-based CBD, including brands, formulations, and reasons for use, in a community pharmacy setting and identify the perceived barriers related to the use of hemp oil-based CBD.

METHODS

A pretested 17-question survey was distributed at the point of care at 2 community pharmacy locations and at hemp oil-based CBD education presentations over a 3-month period. The survey consisted of multiple-choice, open-ended, and select-all-that-apply questions, which were analyzed using univariate and bivariate analyses.

RESULTS

A total of 101 participants completed the survey: 38 were CBD-naive, and 63 were CBD-exposed. Most of the participants were women (79%) and Caucasian (81.6%), with an average age of 59 years (SD 17.26). In the CBD-naive group, the most commonly stated barrier to using hemp oil-based CBD was not enough information about the product. Among the participants who had used or were using at least 1 CBD product, the most commonly used dosage form was sublingual, followed by topical: 46 (46/63 [73%]) and 34 (34/63 [54%]) participants, respectively. Thirty-eight participants used hemp oil-based CBD for pain, 24 participants for sleep, and 17 participants for anxiety. Of these, 62% of the participants informed a health care provider that they were using a hemp oil-based CBD product.

CONCLUSION

The participants were using different brands and formulations of hemp oil-based CBD for multiple reasons. The greatest barrier to trying CBD was limited education, which may suggest a need for community education about hemp oil-based CBD products.

Reasons for cannabidiol use: a cross-sectional study of CBD users, focusing on self-perceived stress, anxiety, and sleep problems

BACKGROUND

Public and medical interest in cannabidiol (CBD) has been rising, and CBD is now available from various sources. Research into the effects of low-dose CBD on outcomes like stress, anxiety, and sleep problems have been scarce, so we conducted an online survey of CBD users to better understand patterns of use, dose, and self-perceived effects of CBD.

METHODS

The sample consisted of 387 current or past-CBD users who answered a 20-question online survey. The survey was sent out to CBD users through email databases and social media. Participants reported basic demographics, CBD use patterns, reasons for use, and effects on anxiety, sleep, and stress.

RESULTS

The sample (N = 387) consisted of 61.2% females, mostly between 25 and 54 years old (72.2%) and primarily based in the UK (77.4%). The top 4 reasons for using CBD were self-perceived anxiety (42.6%), sleep problems (42.5%), stress (37%), and general health and wellbeing (37%). Fifty-four per cent reported using less than 50 mg CBD daily, and 72.6% used CBD sublingually. Adjusted logistic models show females had lower odds than males of using CBD for general health and wellbeing [OR 0.45, 95% CI 0.30-0.72] and post-workout muscle-soreness [OR 0.46, 95%CI 0.24-0.91] but had higher odds of using CBD for self-perceived anxiety [OR 1.60, 95% CI 0.02-2.49] and insomnia [OR 1.87, 95% CI 1.13-3.11]. Older individuals had lower odds of using CBD for general health and wellbeing, stress, post-workout sore muscles, anxiety, skin conditions, focusing, and sleep but had higher odds of using CBD for pain. Respondents reported that CBD use was effective for stress, sleep problems, and anxiety in those who used the drug for those conditions.

CONCLUSION

This survey indicated that CBD users take the drug to manage self-perceived anxiety, stress, sleep, and other symptoms, often in low doses, and these patterns vary by demographic characteristics. Further research is required to understand how low doses, representative of the general user, might impact mental health symptoms like stress, anxiety, and sleep problems.

Vaping-Related Mobile Apps Available in the Google Play Store After the Apple Ban: Content Review

BACKGROUND

In response to health concerns about vaping devices (eg, youth nicotine use, lung injury), Apple removed 181 previously approved vaping-related apps from the App Store in November 2019. This policy change may lessen youth exposure to content that glamorizes vaping; however, it may also block important sources of information and vaping device control for adults seeking to use vaping devices safely.

OBJECTIVE

Understanding the types of nicotine and cannabis vaping-related apps still available in the competing Google Play Store can shed light on how digital apps may reflect information available to consumers.

METHODS

In December 2019, we searched the Google Play Store for vaping-related apps using the keywords "vape" and "vaping" and reviewed the first 100 apps presented in the results. We reviewed app titles, descriptions, screenshots, and metadata to categorize the intended substance (nicotine or cannabis/tetrahydrocannabinol) and the app's purpose. The most installed apps in each purpose category were downloaded and evaluated for quality and usability with the Mobile App Rating Scale.

RESULTS

Of the first 100 apps, 79 were related to vaping. Of these 79 apps, 43 (54%) were specific to nicotine, 3 (4%) were specific to cannabis, 1 (1%) was intended for either, and for the remaining 31 (39%), the intended substance was unclear. The most common purposes of the apps were making do-it-yourself e-liquids (28/79, 35%) or coils (25/79, 32%), games/entertainment (19/79, 24%), social networking (16/79, 20%), and shopping for vaping products (15/79, 19%). Of the 79 apps, at least 4 apps (5%) paired with vaping devices to control temperature or dose settings, 8 apps (10%) claimed to help people quit smoking using vaping, and 2 apps (3%) had the goal of helping people quit vaping.

CONCLUSIONS

The majority of vaping-related apps in the Google Play Store had features either to help users continue vaping, such as information for modifying devices, or to maintain interest in vaping. Few apps were for controlling device settings or assisting with quitting smoking or vaping. Assuming that these Google Play Store apps were similar in content to the Apple App Store apps that were removed, it appears that Apple's ban would have a minimal effect on people who vape with the intention of quitting smoking or who are seeking information about safer vaping via mobile apps.

Online popularity of JUUL and Puff Bars in the USA: 2019-2020

BACKGROUND

The US Food and Drug Administration (FDA) announced a flavour ban on cartridge-based e-cigarettes in January 2020. It is unclear whether e-cigarette users will switch to disposable vaping products with a variety of kids-appealing flavours available.

METHODS

We performed piece-wise regression and autoregressive integrated moving average (ARIMA) algorithms to compare the relative search volume (RSV) of JUUL and Puff Bar (a disposable vaping product) using the 1-year Google Trends data from 24 February 2019 to 20 February 2020, separated by three events that may have spurred changes in RSV for each product.

RESULTS

The RSV for JUUL was relatively stable before Trump Administration announced plans to ban flavoured e-cigarettes. After that, the RSV for JUUL dropped sharply (rate of change=-8.8 per week) from 11 September 2019 to 17 October 2019 when JUUL Labs announced to halt online sales of some flavoured products, and the RSV resumed the decreasing trend after FDA announced enforcement policy of cartridge-based e-cigarettes on 2 January 2020. In comparison, the RSV for Puff Bar started to increase after 11 September 2019 with a low rate of change (0.6) until 17 October 2019. After that, the increase in RSV for Puff Bar accelerated. The RSV of puff bars surpassed that of JUUL during the week of 2 February 2020.

CONCLUSION

The popularity of Puff Bar on Google Search suggests that users may replace cartridge-based vaping products with disposable e-cigarettes in the circumvention of the partial flavour ban. Continuous surveillance and further assessment are needed to prevent potential loopholes in tobacco regulation.

Self-reported Cannabidiol (CBD) Use for Conditions With Proven Therapies

Importance

Use of cannabidiol (CBD) has markedly increased in the past 5 years, concurrent with marketing claims that over-the-counter CBD can be used to treat almost any health condition. However, the reasons why individuals use CBD remain unclear.

Objective

To assess whether individuals are using CBD for diagnosable conditions that have evidence-based therapies.

Design, Setting, and Participants

This case series assessed claimed treatment applications reported by CBD users in public testimonials shared on the Reddit forum r/CBD. The r/CBD forum was selected because it includes a large, naturally occurring sample of 104 917 registered individuals who publicly discuss their experiences using CBD. All r/CBD posts were obtained from January 1, 2014, through August 31, 2019. A random sample of posts was drawn (n = 3000) and filtered to include posts in which self-identified CBD users testified why they take CBD (n = 376).

Exposures

Self-reported use of CBD for medicinal purposes.

Main Outcomes and Measures

Cannabidiol testimonials were divided into 11 subcategories corresponding with the condition's medical subspecialty and 2 subcategories corresponding with wellness benefits. Posts were allowed to receive more than 1 label.

Results

Of the 376 posts labeled as testimonials, 90.0% (95% CI, 86.8%-92.8%) of testimonials claimed that CBD treated the individual's diagnosable conditions. Psychiatric conditions (eg, autism or depression) were the most frequently cited subcategory, mentioned in 63.9% (95% CI, 59.0%-69.1%) of testimonials, followed by orthopedic (26.4%; 95% CI, 21.8%-31.1%), sleep (14.6%; 95% CI, 11.3%-18.5%), and neurological (6.9%; 95% CI, 4.4%-9.6%) conditions. Testimonials also claimed that CBD treated gastroenterological conditions (3.9%; 95% CI, 1.9%-6.1%), as well as addiction, cardiological, dermatological, ophthalmological, oral health, and sexual health conditions (<2.0% each). By contrast, just 29.5% (95% CI, 24.8%-34.2%) of testimonies claimed any wellness benefit, with most citing mental wellness (eg, "quieting my mind") (29.5% [95% CI, 24.2%-34.4%]); 1.4% (95% CI, 0.3%-2.8%) claimed a physical wellness benefit (eg, "exercise performance").

Conclusions and Relevance

The findings of this case series suggest a need for regulation of factors associated with CBD being used to treat diagnosable conditions, engagement of health care professionals with patients on their potential CBD use, and implementation of public health campaigns that encourage the public to seek treatment advice from health care professionals regarding evidence-based therapies.

The effect of cannabidiol on simulated car driving performance: A randomised, double-blind, placebo-controlled, crossover, dose-ranging clinical trial protocol

OBJECTIVE

Interest in the use of cannabidiol (CBD) is increasing worldwide as its therapeutic effects are established and legal restrictions moderated. Unlike Δ9 -tetrahydrocannabinol (Δ9 -THC), CBD does not appear to cause cognitive or psychomotor impairment. However, further assessment of its effects on cognitively demanding day-to-day activities, such as driving, is warranted. Here, we describe a study investigating the effects of CBD on simulated driving and cognitive performance.

METHODS

Thirty healthy individuals will be recruited to participate in this randomised, double-blind, placebo-controlled crossover trial. Participants will complete four research sessions each involving two 30-min simulated driving performance tests completed 45 and 210 min following oral ingestion of placebo or 15, 300, or 1,500 mg CBD. Cognitive function and subjective drug effects will be measured, and blood and oral fluid sampled, at regular intervals. Oral fluid drug testing will be performed using the Securetec DrugWipe® 5S and Dräger DrugTest® 5000 devices to determine whether CBD increases the risk of "false-positive" roadside tests to Δ9 -THC. Noninferiority analyses will test the hypothesis that CBD is no more impairing than placebo.

CONCLUSION

This study will clarify the risks involved in driving following CBD use and assist in ensuring the safe use of CBD by drivers.

The role of cannabidiol oil in schizophrenia treatment. a systematic review and meta-analysis

The purpose of the present meta-analysis was to assess the efficacy of cannabidiol (CBD) oil in patients with schizophrenia. A search was conducted in EMBASE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) up to April 24th, 2020. Randomized clinical trials (RCTs), which used CBD oil treatment versus placebo or any other antipsychotic in schizophrenia patients either as monotherapy or add-on therapy, were included. Data were pooled using a random-effects model. The primary outcomes were efficacy as measured by total symptoms of schizophrenia and improvement in cognition. The meta-analysis was registered with PROSPERO [number: CRD42020157146]. Three double-blind RCTs were included. In one study, CBD oil was compared with amisulpride as monotherapy treatment, but no statistically significant difference in overall efficacy was detected between them. No data were available for cognition. The other two studies estimated the effects of CBD oil as add-on treatment compared to placebo; no significant difference was found either in overall efficacy or in cognition. Altogether, insufficient evidence exists on the efficacy and safety of CBD oil in schizophrenia patients. More RCTs, comparing CBD oil with placebo and other antipsychotics are warranted.

Cannabinoid Use in Musculoskeletal Illness: a Review of the Current Evidence

PURPOSE OF REVIEW

The use of cannabinoids has increased since legalization of recreational and medical use in the USA. It is likely that many orthopaedic patients consume cannabinoid products during the traumatic or perioperative period. The purpose of this study was to investigate the pre-clinical data evaluating the mechanism of action of cannabidiol (CBD) and Δ9-Tetrahydrocannabinol (Δ9-THC) and to evaluate the current clinical data on the use of cannabinoids in musculoskeletal illness.

RECENT FINDINGS

Recent pre-clinical studies have demonstrated that cannabinoid use and the endocannabinoid system (ECS) has an important role in bone healing and bone homeostasis. There is data that suggests that the use of cannabidiol (CBD) may increase bone healing, whereas the use of Δ9-Tetrahydrocannabinol (Δ9-THC), the major psychoactive ingredient in marijuana, likely inhibits bone metabolism and repair. The clinical implications and consumption of marijuana by orthopaedic patients have not been thoroughly evaluated. Studies have demonstrated concern for negative cardiovascular and psychiatric effects caused by marijuana use, but have not yet elucidated outcomes in the orthopaedic literature. With the recent increase in advertising of CBD products and legalization of marijuana, it is likely that many orthopaedic patients are consuming cannabinoid products. The clinical implications and consumption of these products are unclear. We need more robust and well-designed clinical studies prior to making further recommendations to our patients on the consumption of these products.