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Devinsky O, Jones NA, Cunningham MO, Jayasekera BAP, Devore S, Whalley BJ. Cannabinoid treatments in epilepsy and seizure disorders. Physiol Rev 2024; 104:591-649. [PMID: 37882730 DOI: 10.1152/physrev.00049.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 10/17/2023] [Accepted: 10/22/2023] [Indexed: 10/27/2023] Open
Abstract
Cannabis has been used to treat convulsions and other disorders since ancient times. In the last few decades, preclinical animal studies and clinical investigations have established the role of cannabidiol (CBD) in treating epilepsy and seizures and support potential therapeutic benefits for cannabinoids in other neurological and psychiatric disorders. Here, we comprehensively review the role of cannabinoids in epilepsy. We briefly review the diverse physiological processes mediating the central nervous system response to cannabinoids, including Δ9-tetrahydrocannabinol (Δ9-THC), cannabidiol, and terpenes. Next, we characterize the anti- and proconvulsive effects of cannabinoids from animal studies of acute seizures and chronic epileptogenesis. We then review the clinical literature on using cannabinoids to treat epilepsy, including anecdotal evidence and case studies as well as the more recent randomized controlled clinical trials that led to US Food and Drug Administration approval of CBD for some types of epilepsy. Overall, we seek to evaluate our current understanding of cannabinoids in epilepsy and focus future research on unanswered questions.
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Affiliation(s)
- Orrin Devinsky
- Department of Neurology, NYU Grossman School of Medicine, New York, New York, United States
- Department of Neurosurgery, NYU Grossman School of Medicine, New York, New York, United States
- Department of Psychiatry, NYU Grossman School of Medicine, New York, New York, United States
| | | | - Mark O Cunningham
- Discipline of Physiology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - B Ashan P Jayasekera
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Neurosurgery, Royal Victoria Hospital, Newcastle upon Tyne, United Kingdom
| | - Sasha Devore
- Department of Neurology, NYU Grossman School of Medicine, New York, New York, United States
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2
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Bhardwaj AK, Mills L, Doyle M, Sahid A, Montebello M, Monds L, Arunogiri S, Haber P, Lorenzetti V, Lubman DI, Malouf P, Harrod ME, Dunlop A, Freeman T, Lintzeris N. A phase III multisite randomised controlled trial to compare the efficacy of cannabidiol to placebo in the treatment of cannabis use disorder: the CBD-CUD study protocol. BMC Psychiatry 2024; 24:175. [PMID: 38433233 PMCID: PMC10910760 DOI: 10.1186/s12888-024-05616-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/15/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Cannabis use disorder (CUD) is increasingly common and contributes to a range of health and social problems. Cannabidiol (CBD) is a non-intoxicating cannabinoid recognised for its anticonvulsant, anxiolytic and antipsychotic effects with no habit-forming qualities. Results from a Phase IIa randomised clinical trial suggest that treatment with CBD for four weeks reduced non-prescribed cannabis use in people with CUD. This study examines the efficacy, safety and quality of life of longer-term CBD treatment for patients with moderate-to-severe CUD. METHODS/DESIGN A phase III multi-site, randomised, double-blinded, placebo controlled parallel design of a 12-week course of CBD to placebo, with follow-up at 24 weeks after enrolment. Two hundred and fifty adults with moderate-to-severe CUD (target 20% Aboriginal), with no significant medical, psychiatric or other substance use disorders from seven drug and alcohol clinics across NSW and VIC, Australia will be enrolled. Participants will be administered a daily dose of either 4 mL (100 mg/mL) of CBD or a placebo dispensed every 3-weeks. All participants will receive four-sessions of Cognitive Behavioural Therapy (CBT) based counselling. Primary endpoints are self-reported cannabis use days and analysis of cannabis metabolites in urine. Secondary endpoints include severity of CUD, withdrawal severity, cravings, quantity of use, motivation to stop and abstinence, medication safety, quality of life, physical/mental health, cognitive functioning, and patient treatment satisfaction. Qualitative research interviews will be conducted with Aboriginal participants to explore their perspectives on treatment. DISCUSSION Current psychosocial and behavioural treatments for CUD indicate that over 80% of patients relapse within 1-6 months of treatment. Pharmacological treatments are highly effective with other substance use disorders but there are no approved pharmacological treatments for CUD. CBD is a promising candidate for CUD treatment due to its potential efficacy for this indication and excellent safety profile. The anxiolytic, antipsychotic and neuroprotective effects of CBD may have added benefits by reducing many of the mental health and cognitive impairments reported in people with regular cannabis use. TRIAL REGISTRATION Australian and New Zealand Clinical Trial Registry: ACTRN12623000526673 (Registered 19 May 2023).
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Affiliation(s)
- Anjali K Bhardwaj
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia.
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, NSW, Australia.
| | - Llew Mills
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, NSW, Australia
| | - Michael Doyle
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
| | - Arshman Sahid
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, NSW, Australia
| | - Mark Montebello
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug and Alcohol Services, North Sydney Local Health District, St Leonards, NSW, Australia
| | - Lauren Monds
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug and Alcohol Services, North Sydney Local Health District, St Leonards, NSW, Australia
| | - Shalini Arunogiri
- Centre for Addiction and Mental Health, Turning Point, Victoria, Australia
| | - Paul Haber
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug Health Services, Sydney Local Health District, Sydney, Australia
| | | | - Dan I Lubman
- Centre for Addiction and Mental Health, Turning Point, Victoria, Australia
| | - Peter Malouf
- Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Mary E Harrod
- NSW Users and AIDS Association, Sydney, NSW, Australia
| | - Adrian Dunlop
- Drug and Alcohol Clinical Services, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Tom Freeman
- Addiction and Mental Health Group, University of Bath, Bath, UK
| | - Nicholas Lintzeris
- Faculty of Medicine, University of Sydney, Camperdown, NSW, Australia
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, NSW, Australia
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3
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Rivero-Pino F, Casanova AG. Hepatotoxicity due to dietary supplements: state-of-the-art, gaps and perspectives. Crit Rev Toxicol 2023; 53:601-610. [PMID: 38062980 DOI: 10.1080/10408444.2023.2282415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/23/2023] [Indexed: 12/22/2023]
Abstract
Food supplements are products intended to complement the normal diet and consist of concentrated sources of nutrients or other substances with a nutritional or physiological effect. Although they are generally considered safe if the manufacturer's recommendations are followed, many of them have shown hepatotoxic properties. This can cause many diseases (e.g. steatohepatitis and cirrhosis) characterized by progressive damage and malfunction of the liver that in the long term can lead to death. A review of the literature was carried out to elucidate which dietary supplements have been associated with cases of hepatotoxicity in recent years, with emphasis on those relevant to the consumer and the new trends (e.g. cannabidiol). It has been reported that the supplements described as hepatotoxic are mainly of botanical origin (e.g. green tea or turmeric) and those used in sports (mainly anabolic androgenic steroids). There is a great variability of compounds described as causing liver damage, although sometimes it is not possible to identify them, because they are contaminants or adulterants of the products. In addition, the prevalence of toxic effects after the administration of supplements is difficult to define due to underreporting and the lack of specific studies. Globally regarding hepatotoxicity of dietary supplements, there is a paucity of well-conducted clinical trials on the efficacy of these compounds and the frequency of related liver damage, as the use of these products is largely uncontrolled.
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Affiliation(s)
- Fernando Rivero-Pino
- Department of Medical Biochemistry, Molecular Biology, and Immunology, School of Medicine, University of Seville, Seville, Spain
| | - Alfredo G Casanova
- Toxicology Unit, Universidad de Salamanca, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Group of Translational Research on Renal and Cardiovascular Diseases (TRECARD), Salamanca, Spain
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4
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Trojan V, Landa L, Šulcová A, Slíva J, Hřib R. The Main Therapeutic Applications of Cannabidiol (CBD) and Its Potential Effects on Aging with Respect to Alzheimer's Disease. Biomolecules 2023; 13:1446. [PMID: 37892128 PMCID: PMC10604144 DOI: 10.3390/biom13101446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 10/29/2023] Open
Abstract
The use of cannabinoids (substances contained specifically in hemp plants) for therapeutic purposes has received increased attention in recent years. Presently, attention is paid to two main cannabinoids: delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). With respect to the psychotropic effects and dependence potential of THC (though it is very mild), its use is associated with certain restrictions, and thus the therapeutic properties of CBD are frequently emphasized because there are no limitations associated with the risk of dependence. Therefore, this review covers the main pharmacodynamic and pharmacokinetic features of CBD (including characteristics of endocannabinoidome) with respect to its possible beneficial effects on selected diseases in clinical practice. A substantial part of the text deals with the main effects of CBD on aging, including Alzheimer's disease and related underlying mechanisms.
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Affiliation(s)
- Václav Trojan
- International Clinical Research Centre, Cannabis Facility, St. Anne’s University Hospital, Pekařská 53, 602 00 Brno, Czech Republic
| | - Leoš Landa
- International Clinical Research Centre, Cannabis Facility, St. Anne’s University Hospital, Pekařská 53, 602 00 Brno, Czech Republic
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Alexandra Šulcová
- International Clinical Research Centre, Cannabis Facility, St. Anne’s University Hospital, Pekařská 53, 602 00 Brno, Czech Republic
| | - Jiří Slíva
- Department of Pharmacology, Third Faculty of Medicine, Charles University, Ruská 87, 100 00 Prague, Czech Republic
| | - Radovan Hřib
- International Clinical Research Centre, Cannabis Facility, St. Anne’s University Hospital, Pekařská 53, 602 00 Brno, Czech Republic
- Centre for Pain Management, Department of Anesthesiology and Intensive Care, St. Anne’s University Hospital, Pekařská 53, 602 00 Brno, Czech Republic
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5
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Lo LA, Christiansen A, Eadie L, Strickland JC, Kim DD, Boivin M, Barr AM, MacCallum CA. Cannabidiol-associated hepatotoxicity: A systematic review and meta-analysis. J Intern Med 2023; 293:724-752. [PMID: 36912195 DOI: 10.1111/joim.13627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Findings of liver enzyme elevations in recent cannabidiol studies have raised concerns over liver safety. This study aimed to determine the association between cannabidiol use, liver enzyme elevation, and drug-induced liver injury (DILI). METHODS In this systematic review and meta-analysis, a search of EMBASE, CENTRAL, CINAHL, Clinicaltrials.gov, Medline, medRxiv, and Web of Science of records up to February 2022 was conducted. Clinical trials initiating daily cannabidiol treatment with serial liver enzyme measures were included. The proportion of liver enzyme elevations and DILI were independently extracted from published reports. Pooled proportions and probability meta-analyses were conducted. RESULTS Cannabidiol use was associated with an increased probability of liver enzyme elevation (N = 12 trials, n = 1229; OR = 5.85 95% CI = 3.84-8.92, p < 0.001) and DILI (N = 12 trials, n = 1229; OR = 4.82 95% CI = 2.46-9.45, p < 0.001) compared to placebo controls. In participants taking cannabidiol (N = 28 trials, n = 1533), the pooled proportion of liver enzyme elevations was 0.074 (95% CI 0.0448-0.1212), and DILI was 0.0296 (95% CI 0.0136-0.0631). High-dose CBD (≥1000 mg/day or ≥20 mg/kg/day) and concomitant antiepileptic drug use were identified as risk factors. No cases were reported in adults using cannabidiol doses <300 mg/day. No cases of severe DILI were reported. CONCLUSIONS Cannabidiol-associated liver enzyme elevations and DILI meet the criteria of common adverse drug events. Clinicians are encouraged to screen for cannabidiol use and monitor liver function in patients at increased risk.
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Affiliation(s)
- Lindsay A Lo
- Department of Public Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - April Christiansen
- Centre for Neuroscience Studies, Queen's University, Kingston, Ontario, Canada
| | - Lauren Eadie
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Justin C Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David D Kim
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Alasdair M Barr
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,British Columbia Mental Health & Substance Use Services Research Institute, Vancouver, British Columbia, Canada
| | - Caroline A MacCallum
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Shah S, Schwenk ES, Sondekoppam RV, Clarke H, Zakowski M, Rzasa-Lynn RS, Yeung B, Nicholson K, Schwartz G, Hooten WM, Wallace M, Viscusi ER, Narouze S. ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids. Reg Anesth Pain Med 2023; 48:97-117. [PMID: 36596580 DOI: 10.1136/rapm-2022-104013] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/08/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND The past two decades have seen an increase in cannabis use due to both regulatory changes and an interest in potential therapeutic effects of the substance, yet many aspects of the substance and their health implications remain controversial or unclear. METHODS In November 2020, the American Society of Regional Anesthesia and Pain Medicine charged the Cannabis Working Group to develop guidelines for the perioperative use of cannabis. The Perioperative Use of Cannabis and Cannabinoids Guidelines Committee was charged with drafting responses to the nine key questions using a modified Delphi method with the overall goal of producing a document focused on the safe management of surgical patients using cannabinoids. A consensus recommendation required ≥75% agreement. RESULTS Nine questions were selected, with 100% consensus achieved on third-round voting. Topics addressed included perioperative screening, postponement of elective surgery, concomitant use of opioid and cannabis perioperatively, implications for parturients, adjustment in anesthetic and analgesics intraoperatively, postoperative monitoring, cannabis use disorder, and postoperative concerns. Surgical patients using cannabinoids are at potential increased risk for negative perioperative outcomes. CONCLUSIONS Specific clinical recommendations for perioperative management of cannabis and cannabinoids were successfully created.
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Affiliation(s)
- Shalini Shah
- Dept of Anesthesiology & Perioperative Care, UC Irvine Health, Orange, California, USA
| | - Eric S Schwenk
- Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Hance Clarke
- Anesthesiology and Pain Medicine, Univ Toronto, Toronto, Ontario, Canada
| | - Mark Zakowski
- Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Brent Yeung
- Anesthesiology and Perioperative Care, University of California Irvine, Irvine, California, USA
| | | | - Gary Schwartz
- AABP Integrative Pain Care, Melville, New York, USA.,Anesthesiology, Maimonides Medical Center, Brooklyn, New York, USA
| | | | - Mark Wallace
- Anesthesiology, Division of Pain Medicine, University of California San Diego, La Jolla, California, USA
| | - Eugene R Viscusi
- Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
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7
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McCartney D, Kevin RC, Suraev AS, Sahinovic A, Doohan PT, Bedoya-Pérez MA, Grunstein RR, Hoyos CM, McGregor IS. How long does a single oral dose of cannabidiol persist in plasma? Findings from three clinical trials. Drug Test Anal 2023; 15:334-344. [PMID: 36478641 DOI: 10.1002/dta.3419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/10/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
A growing number of clinical trials (CTs) are investigating the therapeutic potential of cannabidiol (CBD), a non-intoxicating phytocannabinoid found in Cannabis sativa. These CTs often use crossover experimental designs requiring 'washout' (clearance) periods. However, the length of time CBD persists in plasma (its 'window of detection') is unclear and could be significant. Indeed, the structurally related phytocannabinoid, Δ9 -tetrahydrocannabinol (THC), has a long window of detection in plasma. We investigated the extent to which CBD and its major metabolites persist in plasma. Data from three CTs that measured plasma cannabinoid concentrations ≥7 days after administering a single oral dose of CBD were pooled. The CBD doses were as follows: CT #1: 300 mg; CT #2: 200 mg (and 10 mg THC); and CT #3: 15, 300 and 1500 mg (one per treatment session). Thirty-two participants were included in the analysis, 17 of whom (from CT #3) provided repeated measures. Overall, 0% (15 mg), 60% (200 mg), 28% (300 mg) and 100% (1500 mg) of participants had detectable concentrations (i.e., >0.25 ng·ml-1 ) of CBD in plasma ≥7 days post-treatment (some, several weeks post-treatment). A zero-inflated negative binomial mixed-effects regression analysis (R2 m = 0.44; R2 c = 0.73) predicted that, on average, a 13 day washout period would reduce plasma CBD concentrations to 'zero' (i.e., <0.25 ng·ml-1 ) if a single oral dose of 300 mg was consumed. Higher doses require longer washout periods; concomitant medications may also affect clearance. In conclusion, CBD has a long window of detection in plasma. Crossover studies involving CBD should, therefore, be conducted with caution, particularly when higher doses and/or chronic dosing regimens are used.
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Affiliation(s)
- Danielle McCartney
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia.,Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia.,School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard C Kevin
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia.,Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia.,School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Anastasia S Suraev
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia.,Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia.,School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Ayshe Sahinovic
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia.,Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia.,School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter T Doohan
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia.,Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia.,School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Miguel A Bedoya-Pérez
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia.,Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia.,School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
| | - Ronald R Grunstein
- Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia.,RPA-Charles Perkins Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Camilla M Hoyos
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia.,School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - Iain S McGregor
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia.,Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia.,School of Psychology, Faculty of Science, The University of Sydney, Sydney, New South Wales, Australia
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8
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Madeo G, Kapoor A, Giorgetti R, Busardò FP, Carlier J. Update on Cannabidiol Clinical Toxicity and Adverse Effects: A Systematic Review. Curr Neuropharmacol 2023; 21:2323-2342. [PMID: 36946485 PMCID: PMC10556379 DOI: 10.2174/1570159x21666230322143401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/15/2023] [Accepted: 01/16/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Compelling evidence from preclinical and clinical studies supports the therapeutic role of cannabidiol (CBD) in several medical disorders. We reviewed the scientific evidence on CBD-related toxicity and adverse events (AEs) in 2019, at the beginning of the spike in clinical studies involving CBD. However, CBD safety remained uncertain. OBJECTIVE With the benefit of hindsight, we aimed to provide an update on CBD-related toxicity and AEs in humans. METHODS A systematic literature search was conducted following PRISMA guidelines. PubMed, Cochrane, and Embase were accessed in October 2022 to identify clinical studies mentioning CBDrelated toxicity/AEs from February 2019 to September 2022. Study design, population characteristics, CBD doses, treatment duration, co-medications, and AEs were compiled. RESULTS A total of 51 reports were included. Most studies investigated CBD efficacy and safety in neurological conditions, such as treatment-resistant epilepsies, although a growing number of studies are focusing on specific psychopathological conditions, such as substance use disorders, chronic psychosis, and anxiety. Most studies report mild or moderate severity of AEs. The most common AEs are diarrhea, somnolence, sedation, and upper respiratory disturbances. Few serious AEs have been reported, especially when CBD is co-administered with other classes of drugs, such as clobazam and valproate. CONCLUSION Clinical data suggest that CBD is well tolerated and associated with few serious AEs at therapeutic doses both in children and adults. However, interactions with other medications should be monitored carefully. Additional data are needed to investigate CBD's long-term efficacy and safety, and CBD use in medical conditions other than epilepsy syndromes.
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Affiliation(s)
- Graziella Madeo
- Clinical Center of Neurology and Psychiatry, Brain&Care Group, Rimini, Italy
| | - Ashita Kapoor
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Raffaele Giorgetti
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Francesco Paolo Busardò
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Jeremy Carlier
- Unit of Forensic Toxicology, Section of Legal Medicine, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
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McCartney D, Suraev AS, Doohan PT, Irwin C, Kevin RC, Grunstein RR, Hoyos CM, McGregor IS. Effects of cannabidiol on simulated driving and cognitive performance: A dose-ranging randomised controlled trial. J Psychopharmacol 2022; 36:1338-1349. [PMID: 35637624 PMCID: PMC9716488 DOI: 10.1177/02698811221095356] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Cannabidiol (CBD), a major cannabinoid of Cannabis sativa, is widely consumed in prescription and non-prescription products. While CBD is generally considered 'non-intoxicating', its effects on safety-sensitive tasks are still under scrutiny. AIM We investigated the effects of CBD on driving performance. METHODS Healthy adults (n = 17) completed four treatment sessions involving the oral administration of a placebo, or 15, 300 or 1500 mg CBD in a randomised, double-blind, crossover design. Simulated driving performance was assessed between ~45-75 and ~210-240 min post-treatment (Drives 1 and 2) using a two-part scenario with 'standard' and 'car following' (CF) components. The primary outcome was standard deviation of lateral position (SDLP), a well-established measure of vehicular control. Cognitive function, subjective experiences and plasma CBD concentrations were also measured. Non-inferiority analyses tested the hypothesis that CBD would not increase SDLP by more than a margin equivalent to a 0.05% blood alcohol concentration (Cohen's dz = 0.50). RESULTS Non-inferiority was established during the standard component of Drive 1 and CF component of Drive 2 on all CBD treatments and during the standard component of Drive 2 on the 15 and 1500 mg treatments (95% CIs < 0.5). The remaining comparisons to placebo were inconclusive (the 95% CIs included 0 and 0.50). No dose of CBD impaired cognition or induced feelings of intoxication (ps > 0.05). CBD was unexpectedly found to persist in plasma for prolonged periods of time (e.g. >4 weeks at 1500 mg). CONCLUSION Acute, oral CBD treatment does not appear to induce feelings of intoxication and is unlikely to impair cognitive function or driving performance (Registration: ACTRN12619001552178).
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Affiliation(s)
- Danielle McCartney
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, NSW, Australia,Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia,School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia,Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, NSW, Australia,Danielle McCartney, Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, 94 Mallett Street, Camperdown, NSW 2050, Australia.
| | - Anastasia S Suraev
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, NSW, Australia,Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia,School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia,Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, NSW, Australia
| | - Peter T Doohan
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, NSW, Australia,Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia,School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
| | - Christopher Irwin
- School of Health Sciences and Social Work, Griffith University, Gold Coast, QLD, Australia,Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD, Australia
| | - Richard C Kevin
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, NSW, Australia,Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia,School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Ronald R Grunstein
- Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, NSW, Australia,RPA-Charles Perkins Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia,Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Camilla M Hoyos
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia,School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia,Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, Sydney, NSW, Australia
| | - Iain S McGregor
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, NSW, Australia,Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia,School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
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10
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Kwee CMB, van Gerven JMA, Bongaerts FLP, Cath DC, Jacobs G, Baas JMP, Groenink L. Cannabidiol in clinical and preclinical anxiety research. A systematic review into concentration-effect relations using the IB-de-risk tool. J Psychopharmacol 2022; 36:1299-1314. [PMID: 36239014 PMCID: PMC9716490 DOI: 10.1177/02698811221124792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Preclinical research suggests that cannabidiol (CBD) may have therapeutic potential in pathological anxiety. Dosing guidelines to inform future human studies are however lacking. AIM We aimed to predict the therapeutic window for anxiety-reducing effects of CBD in humans based on preclinical models. METHODS We conducted two systematic searches in PubMed and Embase up to August 2021, into pharmacokinetic (PK) and pharmacodynamic (PD) data of systemic CBD exposure in humans and animals, which includes anxiety-reducing and potential side effects. Risk of bias was assessed with SYRCLE's RoB tool and Cochrane RoB 2.0. A control group was an inclusion criterion in outcome studies. In human outcome studies, randomisation was required. We excluded studies that co-administered other substances. We used the IB-de-risk tool for a translational integration of outcomes. RESULTS We synthesised data from 87 studies. For most observations (70.3%), CBD had no effect on anxiety outcomes. There was no identifiable relation between anxiety outcomes and drug levels across species. In all species (humans, mice, rats), anxiety-reducing effects seemed to be clustered in certain concentration ranges, which differed between species. DISCUSSION A straightforward dosing recommendation was not possible, given variable concentration-effect relations across species, and no consistent linear effect of CBD on anxiety reduction. Currently, these results raise questions about the broad use as a drug for anxiety. Meta-analytic studies are needed to quantitatively investigate drug efficacy, including aspects of anxiety symptomatology. Acute and (sub)chronic dosing studies with integrated PK and PD outcomes are required for substantiated dose recommendations.
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Affiliation(s)
- Caroline MB Kwee
- Department of Experimental Psychology and Helmholtz Institute, Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands,Altrecht Academic Anxiety Centre, Utrecht, The Netherlands,Caroline MB Kwee, Department of Experimental Psychology and Helmholtz Institute, Faculty of Social and Behavioural Sciences, Utrecht University, Heidelberglaan 1, Utrecht 3584 CS, The Netherlands.
| | | | - Fleur LP Bongaerts
- Department of Experimental Psychology and Helmholtz Institute, Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands
| | - Danielle C Cath
- University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands,Department of Specialist Trainings, GGZ Drenthe, Assen, The Netherlands
| | | | - Johanna MP Baas
- Department of Experimental Psychology and Helmholtz Institute, Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands
| | - Lucianne Groenink
- Department of Pharmaceutical Sciences, Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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11
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Stolar O, Hazan A, Vissoker RE, Kishk IA, Barchel D, Lezinger M, Dagan A, Treves N, Meiri D, Berkovitch M, Kohn E, Heyman E. Medical cannabis for the treatment of comorbid symptoms in children with autism spectrum disorder: An interim analysis of biochemical safety. Front Pharmacol 2022; 13:977484. [PMID: 36249785 PMCID: PMC9559854 DOI: 10.3389/fphar.2022.977484] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Autistic Spectrum Disorder (ASD) is a common neurodevelopmental disorder and no effective treatment for the core symptoms is currently available. The present study is part of a larger clinical trial assessing the effects of cannabis oil on autism co-morbidities.Objectives: The aim of the present study was to assess the safety of a CBD-rich oil treatment in children and adolescents with ASD.Methods: Data from 59 children and young adults (ages 5–25 years) from a single-arm, ongoing, prospective, open-label, one center, phase III study was analyzed. Participants received the Nitzan Spectrum® Oil, with cannabis extracts infused in medium chain triglyceride (MCT) oil with a cannabidiol:THC ratio of 20:1, for 6 months. Blood analysis was performed before treatment initiation, and after 3 months. Complete blood count, glucose, urea, creatinine, electrolytes, liver enzymes (AST, ALT, gamma glutamyl transferase), bilirubin, lipid profile, TSH, FT4, thyroid antibodies, prolactin, and testosterone measurements were performed at baseline, prior to starting treatment and at study midpoint, after 3 months of treatment.Results: 59 children (85% male and 15% female) were followed for 18 ± 8 weeks (mean ±SD). The mean total daily dose was 7.88 ± 4.24 mg/kg body weight. No clinically significant differences were found in any of the analytes between baseline and 3 months follow up. Lactate dehydrogenase was significantly higher before treatment (505.36 ± 95.1 IU/l) as compared to its level after 3 months of treatment (470.55 ± 84.22 IU/L) (p = 0.003). FT4 was significantly higher after 3 months of treatment (15.54 ± 1.9) as compared to its level before treatment (15.07 ± 1.88) (p = 0.03), as was TSH [(2.34 ± 1.17) and (2.05 ± 1.02)] before and after 3 months of treatment, respectively (p = 0.01). However, all these values were within normal range. A comparison of the group with additional medications (n = 14) to those who received solely medical cannabis (n = 45) showed no difference in biochemical analysis, including liver enzymes, which remained stable, except for change in potassium level which was significantly higher in the group that did not receive additional medications (0.04 ± 0.37) compared to the group receiving concomitant drug therapy (-0.2 ± 0.33) (p = 0.04). A comparison of patients who received a high dose of the cannabis oil (upper quartile-16 patients), with those receiving a low dose (lower quartile—14 patients) showed no significant difference between the two groups, except for the mean change of total protein, which was significantly higher among patients receiving high dose of CBD (0.19 ± 2.74) compared to those receiving a low dose of CBD (1.71 ± 2.46 (p = 0.01), and mean change in number of platelets, that was significantly lower among patients who received high dose of CBD (13.46 ± 31.38) as compared to those who received low dose of CBD (29.64 ± 26.2) (p = 0.0007). However, both of these changes lack clinical significance.Conclusion: CBD-rich cannabis oil (CBD: THC 20:1), appears to have a good safety profile. Long-term monitoring with a larger number of participants is warranted.
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Affiliation(s)
- Orit Stolar
- Autism Center/ALUT, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
- *Correspondence: Orit Stolar,
| | - Ariela Hazan
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Roni Enten Vissoker
- Autism Center/ALUT, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Ibrahim Abu Kishk
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Dana Barchel
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Mirit Lezinger
- Pediatric Neurology Department, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Adi Dagan
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Nir Treves
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Meiri
- Technion—Israel Institute of Technology, Haifa, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Elkana Kohn
- Clinical Pharmacology and Toxicology Unit, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
| | - Eli Heyman
- Pediatric Neurology Department, Shamir (Assaf Harofeh) Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Zerifin
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12
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Connor JP, Stjepanović D, Budney AJ, Le Foll B, Hall WD. Clinical management of cannabis withdrawal. Addiction 2022; 117:2075-2095. [PMID: 34791767 PMCID: PMC9110555 DOI: 10.1111/add.15743] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/27/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Cannabis withdrawal is a well-characterized phenomenon that occurs in approximately half of regular and dependent cannabis users after abrupt cessation or significant reductions in cannabis products that contain Δ9 -tetrahydrocannabinol (THC). This review describes the diagnosis, prevalence, course and management of cannabis withdrawal and highlights opportunities for future clinical research. METHODS Narrative review of literature. RESULTS Symptom onset typically occurs 24-48 hours after cessation and most symptoms generally peak at days 2-6, with some symptoms lasting up to 3 weeks or more in heavy cannabis users. The most common features of cannabis withdrawal are anxiety, irritability, anger or aggression, disturbed sleep/dreaming, depressed mood and loss of appetite. Less common physical symptoms include chills, headaches, physical tension, sweating and stomach pain. Despite limited empirical evidence, supportive counselling and psychoeducation are the first-line approaches in the management of cannabis withdrawal. There are no medications currently approved specifically for medically assisted withdrawal (MAW). Medications have been used to manage short-term symptoms (e.g. anxiety, sleep, nausea). A number of promising pharmacological agents have been examined in controlled trials, but these have been underpowered and positive findings not reliably replicated. Some (e.g. cannabis agonists) are used 'off-label' in clinical practice. Inpatient admission for MAW may be clinically indicated for patients who have significant comorbid mental health disorders and polysubstance use to avoid severe complications. CONCLUSIONS The clinical significance of cannabis withdrawal is that its symptoms may precipitate relapse to cannabis use. Complicated withdrawal may occur in people with concurrent mental health and polysubstance use.
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Affiliation(s)
- Jason P. Connor
- National Centre for Youth Substance Use ResearchThe University of QueenslandSt LuciaQLDAustralia,Discipline of Psychiatry, Faculty of MedicineThe University of QueenslandHerstonQLDAustralia
| | - Daniel Stjepanović
- National Centre for Youth Substance Use ResearchThe University of QueenslandSt LuciaQLDAustralia
| | - Alan J. Budney
- Center for Technology and Behavioral HealthGeisel School of Medicine at DartmouthLebanonNHUSA
| | - Bernard Le Foll
- Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental HealthUniversity of TorontoONCanada,Departments of Family and Community Medicine, Psychiatry, Pharmacology and ToxicologyUniversity of TorontoONCanada
| | - Wayne D. Hall
- National Centre for Youth Substance Use ResearchThe University of QueenslandSt LuciaQLDAustralia,Queensland Alliance for Environmental Health SciencesThe University of QueenslandWoolloongabbaQLDAustralia
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13
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Turck D, Bohn T, Castenmiller J, De Henauw S, Hirsch‐Ernst KI, Maciuk A, Mangelsdorf I, McArdle HJ, Naska A, Pelaez C, Pentieva K, Siani A, Thies F, Tsabouri S, Vinceti M, Cubadda F, Frenzel T, Heinonen M, Marchelli R, Neuhäuser‐Berthold M, Poulsen M, Prieto Maradona M, Schlatter JR, Trezza V, van Loveren H, Albert O, Dumas C, Germini A, Gelbmann W, Kass G, Kouloura E, Noriega Fernandez E, Rossi A, Knutsen HK. Statement on safety of cannabidiol as a novel food: data gaps and uncertainties. EFSA J 2022; 20:e07322. [PMID: 35686177 PMCID: PMC9172591 DOI: 10.2903/j.efsa.2022.7322] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The European Commission has determined that cannabidiol (CBD) can be considered as a novel food (NF), and currently, 19 applications are under assessment at EFSA. While assessing these, it has become clear that there are knowledge gaps that need to be addressed before a conclusion on the safety of CBD can be reached. Consequently, EFSA has issued this statement, summarising the state of knowledge on the safety of CBD consumption and highlighting areas where more data are needed. Literature searches for both animal and human studies have been conducted to identify safety concerns. Many human studies have been carried out with Epidyolex®, a CBD drug authorised to treat refractory epilepsies. In the context of medical conditions, adverse effects are tolerated if the benefit outweighs the adverse effect. This is, however, not acceptable when considering CBD as a NF. Furthermore, most of the human data referred to in the CBD applications investigated the efficacy of Epidyolex (or CBD) at therapeutic doses. No NOAEL could be identified from these studies. Given the complexity and importance of CBD receptors and pathways, interactions need to be taken into account when considering CBD as a NF. The effects on drug metabolism need to be clarified. Toxicokinetics in different matrices, the half‐life and accumulation need to be examined. The effect of CBD on liver, gastrointestinal tract, endocrine system, nervous system and on psychological function needs to be clarified. Studies in animals show significant reproductive toxicity, and the extent to which this occurs in humans generally and in women of child‐bearing age specifically needs to be assessed. Considering the significant uncertainties and data gaps, the Panel concludes that the safety of CBD as a NF cannot currently be established.
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14
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Mills L, Lintzeris N, O'Malley M, Arnold JC, McGregor IS. Prevalence and correlates of cannabis use disorder among Australians using cannabis products to treat a medical condition. Drug Alcohol Rev 2022; 41:1095-1108. [PMID: 35172040 DOI: 10.1111/dar.13444] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 12/14/2021] [Accepted: 01/21/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Prior research has examined the prevalence and correlates of cannabis use disorder (CUD) in people who use cannabis; however, these are poorly described for people using cannabis for medical reasons. METHODS Data came from a 2018 to 2019 online, anonymous, cross-sectional survey of Australians reporting using either illicit or licit cannabis for medical reasons within the past year. Included were questions on demographics, current and lifetime patterns of cannabis use, clinical conditions for which medical cannabis was used, and individual criteria for CUD and cannabis withdrawal syndrome. Bayesian Horseshoe logistic regression models were used to identify covariates associated with meeting CUD DSM-5 conditions for any-CUD (≥2/11 criteria) and moderate-severe-CUD (≥4/11). RESULTS A total of 905 participants were included in the analysis. The majority (98%) used illicit cannabis products. Criteria for any-CUD criteria were met by 290 (32.0%), and 117 (12.9%) met criteria for moderate-severe-CUD. Tolerance (21%) and withdrawal (35%) were the most commonly met criteria. Correlates with the strongest association with CUD were inhaled route of administration [odds ratio (OR) = 2.96, 95% credible interval 1.11, 7.06], frequency of cannabis use (OR = 1.24, 1.11-1.35), proportion of cannabis for medical reasons (OR = 0.83, 0.74, 0.94), frequency of tobacco use (OR = 1.10, 1.03, 1.17), age (OR = 0.75, 0.64, 0.90) and pain as main clinical indication (OR = 0.58, 0.36, 1.00). DISCUSSION AND CONCLUSIONS Prevalence of CUD in medical cannabis users appears comparable to 'recreational' users, with many similar correlates. CUD was associated with using cannabis to treat mental health rather than pain conditions and inhaled over other routes of administration.
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Affiliation(s)
- Llewellyn Mills
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, Australia.,Discipline of Addiction Medicine, Faculty of Medicine and Public Health, The University of Sydney, Sydney, Australia.,Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia.,National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Nicholas Lintzeris
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, Australia.,Discipline of Addiction Medicine, Faculty of Medicine and Public Health, The University of Sydney, Sydney, Australia.,Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
| | - Michael O'Malley
- Drug and Alcohol Services, South East Sydney Local Health District, Sydney, Australia.,Discipline of Addiction Medicine, Faculty of Medicine and Public Health, The University of Sydney, Sydney, Australia
| | - Jonathon C Arnold
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, Australia.,Discipline of Pharmacology, Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Brain and Mind Centre, The University of Sydney, Sydney, Australia
| | - Iain S McGregor
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, Australia.,Brain and Mind Centre, The University of Sydney, Sydney, Australia.,School of Psychology, Faculty of Science, The University of Sydney, Sydney, Australia
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15
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Kirkland AE, Fadus MC, Gruber SA, Gray KM, Wilens TE, Squeglia LM. A scoping review of the use of cannabidiol in psychiatric disorders. Psychiatry Res 2022; 308:114347. [PMID: 34952255 PMCID: PMC8799523 DOI: 10.1016/j.psychres.2021.114347] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 02/08/2023]
Abstract
Cannabidiol (CBD) has become a fast-growing avenue for research in psychiatry, and clinicians are challenged with understanding the implications of CBD for treating mental health disorders. The goal of this review is to serve as a guide for mental health professionals by providing an overview of CBD and a synthesis the current evidence within major psychiatric disorders. PubMed and PsycINFO were searched for articles containing the terms "cannabidiol" in addition to major psychiatric disorders and symptoms, yielding 2952 articles. Only randomized controlled trials or within-subject studies investigating CBD as a treatment option for psychiatric disorders (N = 16) were included in the review. Studies were reviewed for psychotic disorders (n = 6), anxiety disorders (n = 3), substance use disorders (tobacco n = 3, cannabis n = 2, opioid n = 1), and insomnia (n = 1). There were no published studies that met inclusion criteria for alcohol or stimulant use disorder, PTSD, ADHD, autism spectrum disorder, or mood disorders. Synthesis of the CBD literature indicates it is generally safe and well tolerated. The most promising preliminary findings are related to the use of CBD in psychotic symptoms and anxiety. There is currently not enough high-quality evidence to suggest the clinical use of CBD for any psychiatric disorder.
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Affiliation(s)
- Anna E Kirkland
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States.
| | - Matthew C Fadus
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Staci A Gruber
- Cognitive and Clinical Neuroimaging Core, Marijuana Investigations for Neuroscientific Discovery (MIND) Program, McLean Hospital, Boston, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Kevin M Gray
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Timothy E Wilens
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Center for Addiction Medicine Co-Director, Massachusetts General Hospital, Boston, MA, United States
| | - Lindsay M Squeglia
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
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16
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Dada S, Ellis SLS, Wood C, Nohara LL, Dreier C, Garcia NH, Saranchova I, Munro L, Pfeifer CG, Eyford BA, Kari S, Garrovillas E, Caspani G, Al Haddad E, Gray PW, Morova T, Lack NA, Andersen RJ, Tjoelker L, Jefferies WA. Specific cannabinoids revive adaptive immunity by reversing immune evasion mechanisms in metastatic tumours. Front Immunol 2022; 13:982082. [PMID: 36923728 PMCID: PMC10010394 DOI: 10.3389/fimmu.2022.982082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/20/2022] [Indexed: 02/24/2023] Open
Abstract
Emerging cancers are sculpted by neo-Darwinian selection for superior growth and survival but minimal immunogenicity; consequently, metastatic cancers often evolve common genetic and epigenetic signatures to elude immune surveillance. Immune subversion by metastatic tumours can be achieved through several mechanisms; one of the most frequently observed involves the loss of expression or mutation of genes composing the MHC-I antigen presentation machinery (APM) that yields tumours invisible to Cytotoxic T lymphocytes, the key component of the adaptive cellular immune response. Fascinating ethnographic and experimental findings indicate that cannabinoids inhibit the growth and progression of several categories of cancer; however, the mechanisms underlying these observations remain clouded in uncertainty. Here, we screened a library of cannabinoid compounds and found molecular selectivity amongst specific cannabinoids, where related molecules such as Δ9-tetrahydrocannabinol, cannabidiol, and cannabigerol can reverse the metastatic immune escape phenotype in vitro by inducing MHC-I cell surface expression in a wide variety of metastatic tumours that subsequently sensitizing tumours to T lymphocyte recognition. Remarkably, H3K27Ac ChIPseq analysis established that cannabigerol and gamma interferon induce overlapping epigenetic signatures and key gene pathways in metastatic tumours related to cellular senescence, as well as APM genes involved in revealing metastatic tumours to the adaptive immune response. Overall, the data suggest that specific cannabinoids may have utility in cancer immunotherapy regimens by overcoming immune escape and augmenting cancer immune surveillance in metastatic disease. Finally, the fundamental discovery of the ability of cannabinoids to alter epigenetic programs may help elucidate many of the pleiotropic medicinal effects of cannabinoids on human physiology.
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Affiliation(s)
- Sarah Dada
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.,Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Samantha L S Ellis
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.,Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Christi Wood
- Biotechnology - Biomedical Science and Technology (BST), University of Applied Sciences, Mannheim, Germany
| | - Lilian L Nohara
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.,Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada
| | - Carola Dreier
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.,Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada.,Biotechnology - Biomedical Science and Technology (BST), University of Applied Sciences, Mannheim, Germany
| | | | - Iryna Saranchova
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Lonna Munro
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Cheryl G Pfeifer
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Brett A Eyford
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Suresh Kari
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada
| | - Emmanuel Garrovillas
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.,Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada.,Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Giorgia Caspani
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.,Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada.,Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | - Eliana Al Haddad
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.,Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada.,Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
| | | | - Tunc Morova
- Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Nathan A Lack
- Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,School of Medicine, Koç University, Istanbul, Türkiye
| | - Raymond J Andersen
- Department of Chemistry, University of British Columbia, Vancouver, BC, Canada
| | | | - Wilfred A Jefferies
- Michael Smith Laboratories, University of British Columbia, Vancouver, BC, Canada.,Vancouver Prostate Centre, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,Centre for Blood Research, University of British Columbia, Vancouver, BC, Canada.,The Djavad Mowafaghian Centre for Brain Health, University of British Columbia, Vancouver, BC, Canada.,Department of Microbiology and Immunology, University of British Columbia, Vancouver, BC, Canada.,Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada.,Department of Zoology, University of British Columbia, Vancouver, BC, Canada.,Department of Urological Science, University of British Columbia, Vancouver, BC, Canada
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17
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Pinto JS, Martel F. Effects of Cannabidiol on Appetite and Body Weight: A Systematic Review. Clin Drug Investig 2022; 42:909-919. [PMID: 36180814 PMCID: PMC9525229 DOI: 10.1007/s40261-022-01205-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Cannabidiol, one of the main components of the Cannabis sativa plant, is a non-psychotropic cannabinoid that has recently drawn the attention of researchers and clinicians for its potential therapeutic applications. In this systematic review, we aim to describe the possible effects of cannabidiol in appetite and body weight. METHODS Both authors independently ran a thorough search in both PubMed and Cochrane databases up to 31 July, 2022 and included every peer-reviewed, original randomized controlled clinical trial that reported data on either of the said outcomes. Risk of assessment bias was performed with Cochrane's risk of bias tool and results were summarized in tables. RESULTS A total of 11 trials were included in this review. Of these, the majority reported on cannabidiol reducing appetite and/or body weight whilst some have found no significant changes and one trial described an increase in appetite. CONCLUSIONS This systematic review suggests that cannabidiol has an anorexigenic effect, correlated with a decrease in body weight. However, most of the studies included in the present review raised some concerns in terms of risk of bias. We believe further research is needed in order to clarify potential mechanisms involved in the effect of cannabidiol on feeding/appetite.
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Affiliation(s)
| | - Fátima Martel
- Department of Biomedicine, Unit of Biochemistry, Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
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18
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Martin EL, Strickland JC, Schlienz NJ, Munson J, Jackson H, Bonn-Miller MO, Vandrey R. Antidepressant and Anxiolytic Effects of Medicinal Cannabis Use in an Observational Trial. Front Psychiatry 2021; 12:729800. [PMID: 34566726 PMCID: PMC8458732 DOI: 10.3389/fpsyt.2021.729800] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/16/2021] [Indexed: 01/04/2023] Open
Abstract
Background: Anxiety and depressive disorders are highly prevalent. Patients are increasingly using medicinal cannabis products to treat these disorders, but little is known about the effects of medicinal cannabis use on symptoms of anxiety and depression. The aim of the present observational study was to assess general health in medicinal cannabis users and non-using controls with anxiety and/or depression. Methods: Participants (368 Cannabis Users; 170 Controls) completed an online survey assessing anxiety and depressive symptoms, cannabis product use, sleep, quality of life, and comorbid chronic pain. Participants that completed this baseline survey were then invited to complete additional follow-up surveys at 3-month intervals. Baseline differences between Cannabis Users and Controls were assessed using independent-samples t-tests and generalized linear mixed effects models were used to assess the impact of initiating cannabis product use, sustained use, or discontinuation of use on anxiety and depressive symptoms at follow-up. Results: Medicinal cannabis use was associated with lower self-reported depression, but not anxiety, at baseline. Medicinal cannabis users also reported superior sleep, quality of life, and less pain on average. Initiation of medicinal cannabis during the follow-up period was associated with significantly decreased anxiety and depressive symptoms, an effect that was not observed in Controls that never initiated cannabis use. Conclusions: Medicinal cannabis use may reduce anxiety and depressive symptoms in clinically anxious and depressed populations. Future placebo-controlled studies are necessary to replicate these findings and to determine the route of administration, dose, and product formulation characteristics to optimize clinical outcomes.
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Affiliation(s)
- Erin L. Martin
- Department of Neuroscience, Medical University of South Carolina, Charleston, SC, United States
| | - Justin C. Strickland
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Nicolas J. Schlienz
- Department of Psychology, University at Buffalo, Buffalo, NY, United States
- Realm of Caring Foundation, Colorado Springs, CO, United States
| | - Joel Munson
- Realm of Caring Foundation, Colorado Springs, CO, United States
| | - Heather Jackson
- Realm of Caring Foundation, Colorado Springs, CO, United States
| | | | - Ryan Vandrey
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Schlag AK, Hindocha C, Zafar R, Nutt DJ, Curran HV. Cannabis based medicines and cannabis dependence: A critical review of issues and evidence. J Psychopharmacol 2021; 35:773-785. [PMID: 33593117 PMCID: PMC8278552 DOI: 10.1177/0269881120986393] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cannabis has been legalised for medical use in an ever-increasing number of countries. A growing body of scientific evidence supports the use of medical cannabis for a range of therapeutic indications. In parallel with these developments, concerns have been expressed by many prescribers that increased use will lead to patients developing cannabis use disorder. Cannabis use disorder has been widely studied in recreational users, and these findings have often been projected onto patients using medical cannabis. However, studies exploring medical cannabis dependence are scarce and the appropriate methodology to measure this construct is uncertain. This article provides a narrative review of the current research to discern if, how and to what extent, concerns about problems of dependence in recreational cannabis users apply to prescribed medical users. We focus on the main issues related to medical cannabis and dependence, including the importance of dose, potency, cannabinoid content, pharmacokinetics and route of administration, frequency of use, as well as set and setting. Medical and recreational cannabis use differs in significant ways, highlighting the challenges of extrapolating findings from the recreational cannabis literature. There are many questions about the potential for medical cannabis use to lead to dependence. It is therefore imperative to address these questions in order to be able to minimise harms of medical cannabis use. We draw out seven recommendations for increasing the safety of medical cannabis prescribing. We hope that the present review contributes to answering some of the key questions surrounding medical cannabis dependence.
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Affiliation(s)
- Anne K Schlag
- Drug Science, St Peter’s House, London, UK
- Neuropsychopharmacology Unit, Centre for Psychiatry, Imperial College London, London, UK
| | - Chandni Hindocha
- Clinical Psychopharmacology Unit, University College London, London, UK
- University College Hospital National Institute of Health Research (NIHR) Biomedical Research Centre, London, UK
| | - Rayyan Zafar
- Drug Science, St Peter’s House, London, UK
- Neuropsychopharmacology Unit, Centre for Psychiatry, Imperial College London, London, UK
| | - David J Nutt
- Drug Science, St Peter’s House, London, UK
- Neuropsychopharmacology Unit, Centre for Psychiatry, Imperial College London, London, UK
| | - H Valerie Curran
- Clinical Psychopharmacology Unit, University College London, London, UK
- University College Hospital National Institute of Health Research (NIHR) Biomedical Research Centre, London, UK
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20
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Morel A, Lebard P, Dereux A, Azuar J, Questel F, Bellivier F, Marie-Claire C, Fatséas M, Vorspan F, Bloch V. Clinical Trials of Cannabidiol for Substance Use Disorders: Outcome Measures, Surrogate Endpoints, and Biomarkers. Front Psychiatry 2021; 12:565617. [PMID: 33692705 PMCID: PMC7937926 DOI: 10.3389/fpsyt.2021.565617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 01/21/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Cannabidiol (CBD) is a cannabinoid of potential interest for the treatment of substance use disorders. Our aim was to review the outcome measures, surrogate endpoints, and biomarkers in published and ongoing randomized clinical trials. Methods: We conducted a search in PubMed, Web of Science, PMC, PsycINFO, EMBASE, CENTRAL Cochrane Library, "clinicalTrials.gov," "clinicaltrialsregister.eu," and "anzctr.org.au" for published and ongoing studies. Inclusion criteria were randomized clinical trials (RCTs) examining the use of CBD alone or in association with other cannabinoids, in all substance use disorders. The included studies were analyzed in detail and their qualities assessed by a standardized tool (CONSORT 2010). A short description of excluded studies, consisting in controlled short-term or single administration in non-treatment-seeking drug users, is provided. Findings: The screening retrieved 207 published studies, including only 3 RCTs in cannabis use disorder. Furthermore, 12 excluded studies in cannabis, tobacco, and opioid use disorders are described. Interpretation: Primary outcomes were validated withdrawal symptoms scales and drug use reduction in the three RCTs. In the short-term or crossover studies, the outcome measures were visual analog scales for subjective states; self-rated scales for withdrawal, craving, anxiety, or psychotomimetic symptoms; and laboratory tasks of drug-induced craving, effort expenditure, attentional bias for substance, impulsivity, or anxiety to serve as surrogate endpoints for treatment efficacy. Of note, ongoing studies are now adding peripheral biomarkers of the endocannabinoid system status to predict treatment response. Conclusion: The outcome measures and biomarkers assessed in the ongoing CBD trials for substance use disorders are improving.
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Affiliation(s)
- Alix Morel
- Département de Psychiatrie et de Médecine Addictologique, Hôpital Lariboisière-Fernand Widal, GHU NORD, Assistance Publique - Hôpitaux de Paris, 200 rue du Fg St Denis, Paris, France
| | - Pierre Lebard
- Département de Psychiatrie et de Médecine Addictologique, Hôpital Lariboisière-Fernand Widal, GHU NORD, Assistance Publique - Hôpitaux de Paris, 200 rue du Fg St Denis, Paris, France
| | - Alexandra Dereux
- Département de Psychiatrie et de Médecine Addictologique, Hôpital Lariboisière-Fernand Widal, GHU NORD, Assistance Publique - Hôpitaux de Paris, 200 rue du Fg St Denis, Paris, France.,INSERM UMRS1144, 4 avenue de l'Observatoire, Paris, France.,FHU NOR-SUD, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Julien Azuar
- Département de Psychiatrie et de Médecine Addictologique, Hôpital Lariboisière-Fernand Widal, GHU NORD, Assistance Publique - Hôpitaux de Paris, 200 rue du Fg St Denis, Paris, France.,INSERM UMRS1144, 4 avenue de l'Observatoire, Paris, France.,FHU NOR-SUD, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Frank Questel
- Département de Psychiatrie et de Médecine Addictologique, Hôpital Lariboisière-Fernand Widal, GHU NORD, Assistance Publique - Hôpitaux de Paris, 200 rue du Fg St Denis, Paris, France.,INSERM UMRS1144, 4 avenue de l'Observatoire, Paris, France.,FHU NOR-SUD, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Frank Bellivier
- Département de Psychiatrie et de Médecine Addictologique, Hôpital Lariboisière-Fernand Widal, GHU NORD, Assistance Publique - Hôpitaux de Paris, 200 rue du Fg St Denis, Paris, France.,INSERM UMRS1144, 4 avenue de l'Observatoire, Paris, France.,FHU NOR-SUD, Assistance Publique - Hôpitaux de Paris, Paris, France.,UFR Médecine, Université de Paris, 3 rue Thomas Mann, Paris, France
| | - Cynthia Marie-Claire
- INSERM UMRS1144, 4 avenue de l'Observatoire, Paris, France.,FHU NOR-SUD, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Mélina Fatséas
- University of Bordeaux, Bordeaux, France.,CNRS-UMR 5287- Institut de Neurosciences Cognitives et Intégratives d'Aquitaine (INCIA), Bordeaux, France.,Pôle d'addictologie, CHU de Bordeaux, Hôpital Haut-Lévêque, Avenue de Magellan, Pessac, France
| | - Florence Vorspan
- Département de Psychiatrie et de Médecine Addictologique, Hôpital Lariboisière-Fernand Widal, GHU NORD, Assistance Publique - Hôpitaux de Paris, 200 rue du Fg St Denis, Paris, France.,INSERM UMRS1144, 4 avenue de l'Observatoire, Paris, France.,FHU NOR-SUD, Assistance Publique - Hôpitaux de Paris, Paris, France.,UFR Médecine, Université de Paris, 3 rue Thomas Mann, Paris, France
| | - Vanessa Bloch
- INSERM UMRS1144, 4 avenue de l'Observatoire, Paris, France.,FHU NOR-SUD, Assistance Publique - Hôpitaux de Paris, Paris, France.,Service de Pharmacie, Hôpital Fernand Widal, GHU NORD, Assistance Publique - Hôpitaux de Paris, 200 rue du Fg St Denis, Paris, France
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Sholler DJ, Huestis MA, Amendolara B, Vandrey R, Cooper ZD. Therapeutic potential and safety considerations for the clinical use of synthetic cannabinoids. Pharmacol Biochem Behav 2020; 199:173059. [PMID: 33086126 PMCID: PMC7725960 DOI: 10.1016/j.pbb.2020.173059] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/22/2020] [Accepted: 10/09/2020] [Indexed: 02/07/2023]
Abstract
The phytocannabinoid Δ9-tetrahydrocannabinol (THC) was isolated and synthesized in the 1960s. Since then, two synthetic cannabinoids (SCBs) targeting the cannabinoid 1 (CB1R) and 2 (CB2R) receptors were approved for medical use based on clinical safety and efficacy data: dronabinol (synthetic THC) and nabilone (synthetic THC analog). To probe the function of the endocannabinoid system further, hundreds of investigational compounds were developed; in particular, agonists with (1) greater CB1/2R affinity relative to THC and (2) full CB1/2R agonist activity. This pharmacological profile may pose greater risks for misuse and adverse effects relative to THC, and these SCBs proliferated in retail markets as legal alternatives to cannabis (e.g., novel psychoactive substances [NPS], "Spice," "K2"). These SCBs were largely outlawed in the U.S., but blanket policies that placed all SCB chemicals into restrictive control categories impeded research progress into novel mechanisms for SCB therapeutic development. There is a concerted effort to develop new, therapeutically useful SCBs that target novel pharmacological mechanisms. This review highlights the potential therapeutic efficacy and safety considerations for unique SCBs, including CB1R partial and full agonists, peripherally-restricted CB1R agonists, selective CB2R agonists, selective CB1R antagonists/inverse agonists, CB1R allosteric modulators, endocannabinoid-degrading enzyme inhibitors, and cannabidiol. We propose promising directions for SCB research that may optimize therapeutic efficacy and diminish potential for adverse events, for example, peripherally-restricted CB1R antagonists/inverse agonists and biased CB1/2R agonists. Together, these strategies could lead to the discovery of new, therapeutically useful SCBs with reduced negative public health impact.
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Affiliation(s)
- Dennis J Sholler
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Marilyn A Huestis
- Institute of Emerging Health Professions, Thomas Jefferson University, Philadelphia, PA, USA
| | - Benjamin Amendolara
- UCLA Cannabis Research Initiative, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
| | - Ryan Vandrey
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ziva D Cooper
- UCLA Cannabis Research Initiative, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
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22
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Watkins PB, Church RJ, Li J, Knappertz V. Cannabidiol and Abnormal Liver Chemistries in Healthy Adults: Results of a Phase I Clinical Trial. Clin Pharmacol Ther 2020; 109:1224-1231. [PMID: 33022751 PMCID: PMC8246741 DOI: 10.1002/cpt.2071] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/27/2020] [Indexed: 12/15/2022]
Abstract
Liver safety concerns were raised in randomized controlled trials of cannabidiol (CBD) in patients with Lennox-Gastaut and Dravet syndromes, but the relevance of these concerns to healthy adults consuming CBD is unclear. The objective of this manuscript is to report on liver safety findings from healthy adults who received therapeutic daily doses of CBD for ~ 3.5 weeks and to investigate any correlation between transaminase elevations and baseline characteristics, pharmacogenetic, and pharmacokinetic data. Sixteen healthy adults were enrolled in a phase I, open-label, fixed single-sequence drug-drug interaction trial to investigate the effect of repeated dose administration of CBD (1,500 mg/day) on cytochrome P450 (CYP) 1A2 activity. Seven (44%) participants experienced peak serum alanine aminotransferase (ALT) values greater than the upper limit of normal (ULN). For five (31%) participants, the value exceeded 5 × ULN, therefore meeting the international consensus criteria for drug-induced liver injury. There was no correlation between transaminase elevations and baseline characteristics, CYP2C19 genotype, or CBD plasma concentrations. All ALT elevations above the ULN began within 2-4 weeks of initial exposure to CBD. Among the six participants with ALT elevations who were discontinued from the protocol, some had symptoms consistent with hepatitis or hypersensitivity. We conclude that healthy adults consuming CBD may experience elevations in serum ALT consistent with drug-induced liver injury. Given the demonstrated interindividual variation in susceptibility, clinicians should be alert to this potential effect from CBD, which is increasingly available in various nonprescription forms and doses to consumers.
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Affiliation(s)
- Paul B Watkins
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy and Institute for Drug Safety Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rachel J Church
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy and Institute for Drug Safety Sciences, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jie Li
- Greenwich Biosciences, 5750 Fleet St Ste 200, Carlsbad, CA, USA
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23
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McGregor IS, Cairns EA, Abelev S, Cohen R, Henderson M, Couch D, Arnold JC, Gauld N. Access to cannabidiol without a prescription: A cross-country comparison and analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 85:102935. [DOI: 10.1016/j.drugpo.2020.102935] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 01/03/2023]
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24
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Ladha KS, McLaren-Blades A, Goel A, Buys MJ, Farquhar-Smith P, Haroutounian S, Kotteeswaran Y, Kwofie K, Le Foll B, Lightfoot NJ, Loiselle J, Mace H, Nicholls J, Regev A, Rosseland LA, Shanthanna H, Sinha A, Sutherland A, Tanguay R, Yafai S, Glenny M, Choi P, Ladak SSJ, Leroux TS, Kawpeng I, Samman B, Singh R, Clarke H. Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process. Br J Anaesth 2020; 126:304-318. [PMID: 33129489 DOI: 10.1016/j.bja.2020.09.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/24/2020] [Accepted: 09/24/2020] [Indexed: 12/14/2022] Open
Abstract
In many countries, liberalisation of the legislation regulating the use of cannabis has outpaced rigorous scientific studies, and a growing number of patients presenting for surgery consume cannabis regularly. Research to date suggests that cannabis can impact perioperative outcomes. We present recommendations obtained using a modified Delphi method for the perioperative care of cannabis-using patients. A steering committee was formed and a review of medical literature with respect to perioperative cannabis use was conducted. This was followed by the recruitment of a panel of 17 experts on the care of cannabis-consuming patients. Panellists were blinded to each other's participation and were provided with rater forms exploring the appropriateness of specific perioperative care elements. The completed rater forms were analysed for consensus. The expert panel was then unblinded and met to discuss the rater form analyses. Draft recommendations were then created and returned to the expert panel for further comment. The draft recommendations were also sent to four independent reviewers (a surgeon, a nurse practitioner, and two patients). The collected feedback was used to finalise the recommendations. The major recommendations obtained included emphasising the importance of eliciting a history of cannabis use, quantifying it, and ensuring contact with a cannabis authoriser (if one exists). Recommendations also included the consideration of perioperative cannabis weaning, additional postoperative nausea and vomiting prophylaxis, and additional attention to monitoring and maintaining anaesthetic depth. Postoperative recommendations included anticipating increased postoperative analgesic requirements and maintaining vigilance for cannabis withdrawal syndrome.
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Affiliation(s)
- Karim S Ladha
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Alexander McLaren-Blades
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Akash Goel
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
| | - Michael J Buys
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Paul Farquhar-Smith
- Department of Anaesthetics, The Royal Marsden NHS Foundation Trust, London, UK
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA
| | - Yuvaraj Kotteeswaran
- Department of Anesthesia, Northern Ontario School of Medicine, Sudbury, Thunder Bay, ON, Canada
| | - Kwesi Kwofie
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Bernard Le Foll
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Acute Care Program, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Division of Brain and Therapeutics, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Nicholas J Lightfoot
- Department of Anaesthesia and Pain Medicine, Counties Manukau Health, Auckland, New Zealand
| | - Joel Loiselle
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Hamish Mace
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley Fremantle Hospital Group, Melville, Australia; University of Western Australia, Perth, Australia
| | - Judith Nicholls
- Department of Anaesthesia, Intensive Care and Pain, Cayman Islands Health Services Authority, George Town, Cayman Islands
| | | | - Leiv Arne Rosseland
- Department of Research and Development, Division of Emergencies and Critical Care, University of Oslo, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Avinash Sinha
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | | | - Rob Tanguay
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada; Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Sherry Yafai
- Releaf Institute, Santa Monica, CA, USA; John Wayne Cancer Institute, Santa Monica, CA, USA
| | - Martha Glenny
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Paul Choi
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Salima S J Ladak
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | | | - Ian Kawpeng
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Bana Samman
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Rajbir Singh
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada
| | - Hance Clarke
- Department of Anesthesia and Pain Management, Toronto General Hospital and University of Toronto, Toronto, ON, Canada; Centre for Cannabinoid Therapeutics, Toronto, ON, Canada.
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Suraev AS, Marshall NS, Vandrey R, McCartney D, Benson MJ, McGregor IS, Grunstein RR, Hoyos CM. Cannabinoid therapies in the management of sleep disorders: A systematic review of preclinical and clinical studies. Sleep Med Rev 2020; 53:101339. [DOI: 10.1016/j.smrv.2020.101339] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 12/21/2022]
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Abstract
The Australian Federal Government legalised access to medicinal cannabis in 2016 More than 100 different cannabis products are now available to prescribe. Most are oral preparations (oils) or capsules containing delta-9-tetrahydrocannabinol or cannabidiol. Dried-flower products are also available As most products are unregistered drugs, prescribing requires approval under the Therapeutic Goods Administration Special Access Scheme-B or Authorised Prescriber Scheme Special Access Scheme Category B applications can be made online, with approval usually being given within 24–48 hours. However, supply chain problems may delay dispensing by the pharmacy By the end of 2019, over 28,000 prescribing approvals had been issued to patients, involving more than 1400 doctors, mostly GPs. More than 70,000 approvals are projected by the end of 2020 Most prescriptions are for chronic non-cancer pain, anxiety, cancer-related symptoms, epilepsy and other neurological disorders. However, the evidence supporting some indications is limited Many doctors are cautious about prescribing cannabis. While serious adverse events are rare, there are legitimate concerns around driving, cognitive impairment and drug dependence with products containing delta-9-tetrahydrocannabinol. Cannabidiol-only products pose fewer risks
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Affiliation(s)
- Jonathon C Arnold
- University of Sydney.,National Institute of Integrative Medicine, Melbourne
| | - Tamara Nation
- University of Sydney.,National Institute of Integrative Medicine, Melbourne
| | - Iain S McGregor
- University of Sydney.,National Institute of Integrative Medicine, Melbourne
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27
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Dos Santos RG, Guimarães FS, Crippa JAS, Hallak JEC, Rossi GN, Rocha JM, Zuardi AW. Serious adverse effects of cannabidiol (CBD): a review of randomized controlled trials. Expert Opin Drug Metab Toxicol 2020; 16:517-526. [PMID: 32271618 DOI: 10.1080/17425255.2020.1754793] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Recent trials using cannabidiol (CBD) have shown that most acute and prolonged adverse effects of CBD are mild to moderate, with rare serious adverse effects (SAEs). This review focused on analyzing SAEs of CBD and their possible relation to drug-drug interactions. AREAS COVERED We systematically analyzed the SAEs reported in randomized controlled trials (RCTs) involving the administration of oral CBD for at least 1 week in both healthy volunteers and clinical samples. EXPERT OPINION SAEs related to CBD in RCT are rare and include mainly elevated transaminases, convulsion, sedation, lethargy, and upper respiratory tract infections. Elevated transaminases are related to concomitant valproate use, while sedation, lethargy, and upper respiratory tract infections are related to concomitant clobazam use. Epileptic patients should be monitored when using CBD concomitantly with these and other antiepileptic drugs for other possible drug-drug interactions.
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Affiliation(s)
- Rafael G Dos Santos
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil.,National Institute of Science and Technology - Translational Medicine , Brazil
| | - Francisco S Guimarães
- National Institute of Science and Technology - Translational Medicine , Brazil.,Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - José Alexandre S Crippa
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil.,National Institute of Science and Technology - Translational Medicine , Brazil
| | - Jaime E C Hallak
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil.,National Institute of Science and Technology - Translational Medicine , Brazil
| | - Giordano Novak Rossi
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Juliana Mendes Rocha
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil
| | - Antônio W Zuardi
- Department of Neurosciences and Behavior, Ribeirão Preto Medical School, University of São Paulo , Ribeirão Preto, Brazil.,National Institute of Science and Technology - Translational Medicine , Brazil
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