Cannabidiol (CBD) in Dietary Supplements: Perspectives on Science, Safety, and Potential Regulatory Approaches

Evaluation of cannabidiol-based products in Brazil: how can current regulations influence their labeling quality?

There is concern about the quality of cannabis-based products used in Brazil, mainly cannabidiol (CBD). This study aimed to evaluate the quality of labeling on CBD products marketed in Brazil authorized by two regulations - N660/2022 on imported products and N327/2019 on products with temporary trade permits - and whether there were differences between them concerning four domains: prescription, good manufacturing practices (GMP), laboratory tests, and safety of use. Determined labeling quality was based on a score of 45 criteria divided per domain and weights from 1 to 3 (according to the relevance for users' and prescribers' safety) built by public information provided by product manufacturers/representatives on websites and e-mail consultations. The quality score was classified as very satisfactory, satisfactory, or not very satisfactory, represented in median and interquartile range. Between the N327 and N660 products, the quality scores were compared using the Mann-Whitney U-test. All tests considered two-tailed hypotheses and a significance level of 5%. After applying the inclusion criteria, from 148 products selected, 105 were evaluated. Most of the evaluated CBD products were classified as satisfactory (47), followed by not very satisfactory (39) and very satisfactory (19). The N327 products presented information that was more accessible than the N660 products. Similarly, there was a significant difference between the two groups concerning the domains of prescription and safety of use; products in the N327 showed better results than those in the N660. This study contributes to the urgent debate on the quality of labeling and the risks of CBD widely marketed in Brazil.

Twin-screw extrusion retains industrial hemp byproduct (hemp flakes) functionality

Consumer recognition of the health benefits of industrial hemp cannabidiol (CBD) products has increased its value to consumers. Consequently, there is a need to explore industrial hemp byproducts to improve sustainability and foster a circular economy. Extrusion processing was conducted with formulations made with hemp flakes, a byproduct of CBD oil extraction based on corn flour with 5%, 10%, and 15% hemp flakes replacement using a laboratory-scale conical twin-screw extruder. The impacts of formulation, barrel temperature, and screw speed on extrudates were evaluated. Cannabichromene (CBC), cannabinol (CBN), cannabidiolic acid (CBDA), cannabigerol (CBG), and CBD were determined with high-performance liquid chromatography before and postextrusion. Antioxidant potential (total polyphenol content [TPC] and 1,1-diphenyl-1-picrylhydrazyl radical scavenging assay [DPPH]) and ferric-reducing antioxidant potential (FRAP) were determined similarly. Increasing hemp flakes in the formula reduced pasting properties significantly (p ≤ 0.05). Expansion ratio (ER) showed significant linear effects with the amount of hemp flakes in the formula (p ≤ 0.05) and die temperature (p ≤ 0.05), while the 10% hemp formula recorded the highest ER of 3.24 (p ≤ 0.05). Extrusion generally reduced TPC, DPPH, FRAP, and cannabinoids compared to raw formulas. Low screw speeds and medium barrel temperatures displayed high retention of cannabinoids and antioxidants. Low screw speeds might have allowed adequate shearing, mixing, and an extended high-pressure exposure leading to the release of bound polyphenols, antioxidants, and cannabinoids. Some extrusion parameters can maintain cannabinoids and antioxidants in hemp byproducts while transforming them into puffed food products. These findings directly affect the industry, providing valuable insights for practical application. PRACTICAL APPLICATION: Extrusion cooking remains one of the most economical methods of valorizing agricultural byproducts. This work developed extrusion parameters applicable to the food industry for making quality puffed food products. It could apply to snacks, breakfast cereals, animal feed, and others with desirable consumer properties and retained functionality for improving health and wellness.

A 96-position platform for magnetic sorbent-based dispersive microextraction: Application to the determination of tetrahydrocannabinol and cannabidiol in saliva of cannabis smokers

BACKGROUND

In order to obtain sustainable analytical methods, it is essential to develop kinetically efficient sample preparation strategies in which equilibria are reached faster, as dispersive extraction techniques. In addition, the higher the reduction in size, the higher number of extraction vessels can be located and thus the higher number of samples can be simultaneously treated. All this increases sample throughput, and contributes to the reduction of chemical waste, and energy and sample consumption. In this sense, multiposition extraction platforms are smart strategies to achieve these goals, but they are scarcely developed for dispersive extraction techniques.

RESULTS

Taking miniaturized stir bar sorptive dispersive microextraction (mSBSDME) as a starting point, a 96-position extraction platform has been developed using a 96-position stirring plate and a tailor-designed 3D-printed support for locating the miniaturized extraction vessels, achieving a high-throughput miniaturized sample preparation strategy. In order to show the applicability of this novel platform, the determination of Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) in human saliva has been carried out and applied to samples collected after the consumption of marijuana and legal CBD-rich cannabis. Only 100 μL of saliva were needed for the analysis and good analytical features in terms of linearity (at least up to 500 ng mL-1), limits of detection (0.7 and 2.8 ng mL-1 for THC and CBD, respectively), and precision (RSD ≤ 14 %) were achieved.

SIGNIFICANCE

The miniaturization of the vessel allows the use of small volumes of sample (i.e., a few microliters) and the treatment of 96 samples in parallel, being the first proposal for carrying out dispersive sorbent-based microextraction under the concept of 96-well format. Additionally, this new workflow contributes to the development of analytical methods that meet the three pillars of sustainability, i.e., greenness and easily affordable in terms of economics and applicability.

Human quad liver-on-chip system as a tool toward bridging the gap between animals and humans regarding toxicology and pharmacology of a cannabidiol-rich cannabis extract

Cannabidiol (CBD) is a major phytocannabinoid from Cannabis sativa. It is currently widely available and widely used in the USA, but despite its rapid progress to market, the pharmacology and toxicology of both CBD and cannabidiol-rich cannabis extracts (CRCE) remain largely unknown. The goals of this study were to investigate the potential of a novel human microphysiological system to emulate CRCE-induced hepatotoxicity and pharmacological properties demonstrated in animal models. For this purpose, C57BL6/J male mice were subjected to dosing with either 0, 61.5, 184.5, or 615 mg/kg of CRCE for 10 days. The liver-on-chip system, incorporating human primary hepatocytes, sinusoidal endothelial cells, as well as Kupffer and stellate cells was subjected to 0, 300, 1,200, or 4,400 ng/mL of CRCE (8 h exposure followed by 16 h washout) for 5 days. Administration of CRCE in mice resulted in nearly 4-fold elevations of plasma ALT at 615 mg/kg (p < 0.01) and a dose-dependent decrease in intrahepatic miR-122. Elevated levels of ALT, paralleled by decreased intrahepatic and increased effluent levels of miR-122, were also observed in the liver-on-chip, although these results were not statistically significant. Exposure to CRCE resulted in a robust and dose-dependent induction of key cytochrome P450 enzymes, namely Cyp1a2, Cyp2b6 (CYP2B10), Cyp2e1, and Cyp2c9 (CYP2C19) in both mouse livers and liver-on-chip. The results of this study demonstrate the congruence between the responses observed in mouse and human liver-on-chip experimental systems and provide evidence of the potential microphysiological systems hold for translating animal data into clinical practice.

CBD oil by-product (Hemp flakes): Evaluation for nutritional composition, heavy metals and functionality as a food ingredient

Background

The recent interest among consumers in industrial hemp due to health and wellness benefits has led to several products from industrial hemp, including cannabidiol (CBD) oil. CBD oil extraction from hemp buds and flowers generates by-product biomass (hemp flakes), often posing disposal challenges and with little or no applications. We hypothesized that hemp flakes possess residual compounds with nutritional and health value that could be used to improve utilization.

Methods

Locally sourced hemp flakes were compared to three commercial hemp protein products. The nutritional composition (proximate analysis), heavy metals (Al, Cu, As, Pb, Co, Cd), and functional composition (phenolic and antioxidant properties-total phenolic compounds (TPC), total flavonoid compounds (TFC), ferric reducing antioxidant potential (FRAP), 1,1-diphenyl-1-picrylhydrazyl (DPPH), Trolox equivalent antioxidant capacity (TEAC)), (CBD, cannabiodiolic acid-CBDA, cannabichromene-CBC, cannabigerol-CBG, and cannabinol-CBN) contents were determined and compared.

Findings

Hemp flakes had a similar nutritional composition to commercial hemp protein products, with heavy metal levels within FDA allowed limits. The by-product had significantly higher CBDA levels than commercial products. Overall, hemp flakes had comparable nutrient composition and antioxidant capabilities. Based on the protein composition of hemp flakes (31.62 %) versus the highest commercial product (43 %), hemp flakes are an acceptable functional food ingredient.

Differences in Cannabidiol-Related Attitudes and Practice Behaviors Between U.S. Primary Care Physicians Practicing in a Single Health Care System Across States With and Without Marijuana Legalization

Introduction: Dramatic shifts in marijuana laws, along with federal deregulation of hemp with the 2018 Farm Bill, have resulted in increased availability and use of cannabidiol (CBD) supplements throughout the United States (US). Given the rapid increase in CBD use in the U.S. general population, in this study, we aim to characterize primary care physician (PCP) attitudes and practice behaviors and to assess whether differences in provider attitudes and behaviors vary as a function of marijuana legalization (ML) status in the state of practice. Materials and Methods: Data are from an online provider survey on CBD supplement-related attitudes, beliefs, and behaviors administered to 508 PCPs as part of a larger mixed methods study. Participating PCPs were recruited from the Mayo Clinic Healthcare Network and provided medical care in primary care settings across four U.S. states (Minnesota, Wisconsin, Florida, and Arizona). Results: The survey response rate was 45.4% (n=236/508). According to providers, CBD was frequently brought up in PCP settings, typically by patients. PCPs were generally hesitant to screen for or discuss CBD with their patients and identified multiple barriers to open patient-provider dialogue about CBD. PCPs practicing in states that had passed ML were more receptive to patients using CBD supplements, whereas PCPs practicing in states that had not passed ML were more concerned about CBD-related side effects. Regardless of state ML status, most PCPs did not feel that they should be recommending CBD supplements to their patients. Most PCPs reported believing that CBD was unhelpful for most conditions for which it is marketed, with chronic non-cancer pain and anxiety/stress being exceptions. PCP respondents generally felt that they had insufficient knowledge/training around CBD. Conclusions: Results from this mixed methods study show that PCPs practicing in the U.S. rarely screen for or discuss CBD use with their patients and report several barriers to engage in proactive CBD-focused practice behaviors. Furthermore, survey results show that some PCP attitudes, practice behaviors, and barriers vary as a function of state ML status. These findings may guide medical education efforts and inform primary care practice modifications aimed at enhancing screening and monitoring of patient CBD use by PCPs.

Phytocannabinoids: Exploring Pharmacological Profiles and Their Impact on Therapeutical Use

Phytocannabinoids, a diverse group of naturally occurring compounds extracted from the Cannabis plant, have attracted interest due to their potential pharmacological effects and medicinal uses. This comprehensive review presents the intricate pharmacological profiles of phytocannabinoids while exploring the diverse impacts these substances have on biological systems. From the more than one hundred cannabinoids which were identified in the Cannabis plant so far, cannabidiol (CBD) and tetrahydrocannabinol (THC) are two of the most extensively studied phytocannabinoids. CBD is a non-psychoactive compound, which exhibits potential anti-inflammatory, neuroprotective, and anxiolytic properties, making it a promising candidate for a wide array of medical conditions. THC, known for its psychoactive effects, possesses analgesic and antiemetic properties, contributing to its therapeutic potential. In addition to THC and CBD, a wide range of additional phytocannabinoids have shown intriguing pharmacological effects, including cannabichromene (CBC), cannabigerol (CBG), and cannabinol (CBN). The endocannabinoid system, made up of the enzymes involved in the production and breakdown of endocannabinoids, cannabinoid receptors (CB1 and CB2), and endogenous ligands (endocannabinoids), is essential for preserving homeostasis in several physiological processes. Beyond their effects on the endocannabinoid system, phytocannabinoids are studied for their ability to modify ion channels, neurotransmitter receptors, and anti-oxidative pathways. The complex interaction between phytocannabinoids and biological systems offers hope for novel treatment approaches and lays the groundwork for further developments in the field of cannabinoid-based medicine. This review summarizes the state of the field, points out information gaps, and emphasizes the need for more studies to fully realize the therapeutic potential of phytocannabinoids.

Cannabidiol usage, efficacy, and side effects: analyzing the impact of health conditions, medications, and cannabis use in a cross-sectional online pilot study

BACKGROUND

Products containing cannabidiol (CBD) are attracting attention because of their potential therapeutic benefits and positive impacts on well-being and mental health. Although additional research is needed to understand their effectiveness in treating mental disorders, cross-sectional studies may help identify the factors influencing CBD use patterns. This study examined the impact of variables such as health status, medication use, medical supervision, gender, age, and cannabis use on CBD consumption patterns.

MATERIALS AND METHODS

A self-selected sample (n =267) of current or former CBD users was recruited via social media and participated in an online survey designed to collect data on basic demographics, health status, cannabis use, and CBD usage patterns.

RESULTS

The sample (n = 267) consisted of 68.5% women with an average age of 30.21 years, of which 25.8% reported diagnosed psychiatric disorders and 49.4% reported cannabis use. The top five reasons for using CBD were self-reported stress (65.3%), sleep problems (51.7%), overall improvement in well-being (52.5%), improved mood (44.9%), and anxiety relief (40.9%). Our findings suggest that individuals with psychiatric disorders and those taking psychotropic medications are more likely to use CBD to relieve stress and anxiety. Overall, nearly 70% of the individuals found CBD products to be effective. Sublingual administration was more popular among non-cannabis users, while cannabis users preferred smoking and vaping to CBD administration.

CONCLUSION

Our results indicate that individuals using CBD for health and wellness reasons believe that it has potential health benefits. Further research using rigorous longitudinal designs is needed to delve deeper into the effectiveness of low-dose CBD and to better understand the therapeutic potential of CBD.

Reported exposures to derived cannabis products in California before and after the 2018 federal reclassification of hemp

BACKGROUND

As of June 2023, a majority of states had legalized the sale of cannabis, which past research has found to be associated with increased exposures. In 2018, a change in federal policy increased access to cannabidiol (CBD) and derived psychoactive cannabis products, but there has been limited study of reported exposures following this change.

METHODS

This observational retrospective study analyzed exposures involving synthetic cannabinoid receptor agonists (SCRAs) and derived cannabis products, including CBD, reported to the California Poison Control System (CPCS) from 2010 to 2022. We focused primarily on potential shifts in reported exposures before and after the implementation of the 2018 Farm Bill, which removed products derived from hemp from the Controlled Substances Act. We reviewed and hand-coded individual call records to assess reported exposures over time and their characteristics, and conducted interrupted time series analysis to assess whether exposure counts changed after policy interventions.

RESULTS

Reported CBD exposures significantly increased following the federal reclassification of hemp products. Exposure reports were most common among young children and for edibles. Exposure reports provided limited information about derived psychoactive cannabis products.

CONCLUSIONS

Our findings suggest a need for improved data collection regarding derived psychoactive cannabis products, as well as potential public health value in modifying packaging regulations and in providing additional guidance to parents to help prevent CBD exposures.

Symptom severity is a major determinant of cannabis-based products use among people with multiple sclerosis

AIMS AND OBJECTIVES

We aimed to identify correlates of cannabinoid-based products (CBP) use in patients with multiple sclerosis (MS) in France and Spain.

BACKGROUND

MS is responsible for a wide range of symptoms, including pain. Access to CBP differs according to local legislation. The French context is more restrictive than the Spanish one, and no data regarding cannabis use among MS patients has yet been published. Characterizing MS patients who use CBP constitutes a first step toward identifying persons most likely to benefit from them.

DESIGN

An online cross-sectional survey was submitted to MS patients who were members of a social network for people living with chronic diseases and were living in France or Spain.

METHODS

Two study outcomes measured therapeutic CBP use and daily therapeutic CBP use. Seemingly unrelated bivariate probit regression models were used to test for associations between the outcomes and patients' characteristics while accounting for country-related differences. STROBE guidelines were followed in reporting this study.

RESULTS

Among 641 study participants (70% from France), the prevalence of CBP use was similar in both countries (23.3% in France vs. 20.1% in Spain). MS-related disability was associated with both outcomes, with a gradient observed between different degrees of disability. MS-related pain level was associated with CBP use only.

CONCLUSIONS

CBP use is common in MS patients from both countries. The more severe the MS, the more participants turned to CBP to alleviate their symptoms. Easier access to CBP should be ensured for MS patients in need of relief, especially from pain.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the characteristics of MS patients using CBP. Such practices should be discussed by healthcare professional with MS patients.

Cannabidiol (CBD) for the treatment of subcutaneous treprostinil (Remodulin®) site pain: a case report

Background

Pulmonary arterial hypertension occurs as a result of vascular remodeling and dysregulation of endothelial cells that narrows small pulmonary arteries and raises precapillary pressures. Pulmonary arterial hypertension is a rare and progressive disease characterized by dyspnea, chest pain, and syncope. Parenteral treprostinil is indicated for the treatment of pulmonary arterial hypertension to diminish symptoms associated with exercise. Up to 92% of patients treated with treprostinil via subcutaneous delivery experienced infusion site pain and approximately 23% discontinued treatment due to site pain. Cannabidiol salve may have analgesic and anti-inflammatory properties and could be an additional option for patients with infusion site pain.

Case report

Two patients with pulmonary arterial hypertension were treated with cannabidiol salve. Both patients reported a reduction in infusion site pain without the need for narcotics.

Conclusion

These two cases suggest that cannabidiol salve may help to minimize redness and alleviate pain at the infusion site. Additional studies are required to test the effectiveness of cannabidiol in a larger group of patients with infusion site pain.

Hepatotoxicity due to herbal dietary supplements: Past, present and the future

Dietary supplements (DS) constitute a widely used group of products comprising vitamin, mineral, and botanical extract formulations. DS of botanical or herbal origins (HDS) comprise nearly 30% of all DS and are presented on the market either as single plant extracts or multi-extract-containing products. Despite generally safe toxicological profiles of most products currently present on the market, rising cases of liver injury caused by HDS - mostly by multi-ingredient and adulterated products - are of particular concern. Here we discuss the most prominent historical cases of HDS-induced hepatotoxicty - from Ephedra to Hydroxycut and OxyELITE Pro-NF, as well as products with suspected hepatotoxicity that are either currently on or are entering the market. We further provide discussion on overcoming the existing challenges with HDS-linked hepatotoxicity by introduction of advanced in silico, in vitro, in vivo, and microphysiological system approaches to address the matter of safety of those products before they reach the market.

Analysis of COVID-19 Pandemic on Supplement Usage and Its Combination with Self-Medication within the State of Arkansas

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus responsible for the COVID-19 pandemic that can lead to severe respiratory distress requiring hospitalization and can be fatal. Media have reported that various dietary supplements (DS) or their combination with different medications can prevent infection or decrease disease severity. Here, we analyzed data collected from 15,830 patient follow-up telephone interviews from the University of Arkansas for Medical Sciences COVID-19 testing sites from March 15 to August 1, 2020. Within the REDCap database, we recorded patient demographics and DS and medication use. In total, data on DS and medication use was available for 8,150 study participants, of whom 21.9% and 4.1% reported using DS or medications, respectively, to either prevent or treat COVID-19. The majority of respondents were female (64%) and non-Hispanic whites (44.5%). Most individuals (64.5%) who took DS were younger than 50 years of age. Products such as vitamin C (1,013, 33.2%), multivitamins (722, 23.6%), and vitamin D (294, 9.6%) were the most commonly used DS among the responders. Analysis of the DS use and symptom scores association did not provide a strong evidence of beneficial health effects of DS. The results of this study demonstrate that a significantly higher proportion of study participants considered usage of DS to mitigate or prevent COVID-19-related symptoms compared to those who preferred medications. However, lack of observable health benefits associated with ingestion of DS suggests that more rigorous research is needed to substantiate the label claims.

Regulating for Safety: Cannabidiol Dose in Food: A Review

ABSTRACT

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

HIGHLIGHTS

Differentiating Cannabis Products: Drugs, Food, and Supplements

“Hemp” refers to non-intoxicating, low delta-9 tetrahydrocannabinol (Δ9-THC) cultivars of Cannabis sativa L. “Marijuana” refers to cultivars with high levels of Δ9-THC, the primary psychoactive cannabinoid found in the plant and a federally controlled substance used for both recreational and therapeutic purposes. Although marijuana and hemp belong to the same genus and species, they differ in terms of chemical and genetic composition, production practices, product uses, and regulatory status. Hemp seed and hemp seed oil have been shown to have valuable nutritional capacity. Cannabidiol (CBD), a non-intoxicating phytocannabinoid with a wide therapeutic index and acceptable side effect profile, has demonstrated high medicinal potential in some conditions. Several countries and states have facilitated the use of THC-dominant medical cannabis for certain conditions, while other countries continue to ban all forms of cannabis regardless of cannabinoid profile or low psychoactive potential. Today, differentiating between hemp and marijuana in the laboratory is no longer a difficult process. Certain thin layer chromatography (TLC) methods can rapidly screen for cannabinoids, and several gas and liquid chromatography techniques have been developed for precise quantification of phytocannabinoids in plant extracts and biological samples. Geographic regulations and testing guidelines for cannabis continue to evolve. As they are improved and clarified, we can better employ the appropriate applications of this uniquely versatile plant from an informed scientific perspective.

Geospatiotemporal and causal inference study of cannabis and other drugs as risk factors for female breast cancer USA 2003-2017

Breast cancer (BC) is the commonest human cancer and its incidence (BC incidence, BCI) is rising worldwide. Whilst both tobacco and alcohol have been linked to BCI genotoxic cannabinoids have not been investigated. Age-adjusted state-based BCI 2003-2017 was taken from the Surveillance Epidemiology and End Results database of the Centers for Disease Control. Drug use from the National Survey of Drug Use and Health, response rate 74.1%. Median age, median household income and ethnicity were from US census. Inverse probability weighted (ipw) multivariable regression conducted in R. In bivariate analysis BCI was shown to be significantly linked with rising cannabis exposure {β-est. = 3.93 [95% confidence interval 2.99, 4.87], P = 1.10 × 10-15}. At 8 years lag cigarettes:cannabis [β-est. = 2660 (2150.4, 3169.3), P = 4.60 × 10-22] and cannabis:alcoholism [β-est. = 7010 (5461.6, 8558.4), P = 1.80 × 10-17] were significant in ipw-panel regression. Terms including cannabidiol [CBD; β-est. = 16.16 (0.39, 31.93), P = 0.446] and cannabigerol [CBG; β-est. = 6.23 (2.06, 10.39), P = 0.0034] were significant in spatiotemporal models lagged 1:2 years, respectively. Cannabis-liberal paradigms had higher BCI [67.50 ± 0.26 v. 65.19 ± 0.21/100 000 (mean ± SEM), P = 1.87 × 10-11; β-est. = 2.31 (1.65, 2.96), P = 9.09 × 10-12]. 55/58 expected values >1.25 and 13/58 >100. Abortion was independently and causally significant in space-time models. Data show that exposure to cannabis and the cannabinoids Δ9-tetrahydrocannabinol, CBD, CBG and alcoholism fulfil quantitative causal criteria for BCI across space and time. Findings are robust to adjustment for age and several known sociodemographic, socio-economic and hormonal risk factors and establish cannabinoids as an additional risk factor class for breast carcinogenesis. BCI is higher under cannabis-liberal legal paradigms.

Congenital anomaly epidemiological correlates of Δ8THC across USA 2003-16: panel regression and causal inferential study

Δ8-Tetrahydrocannabinol (Δ8THC) is marketed in many US states as 'legal weed'. Concerns exist relating to class-wide genotoxic cannabinoid effects. We conducted an epidemiological investigation of Δ8THC-related genotoxicity expressed as 57 congenital anomaly (CA) rates (CARs) in the USA. CARs were taken from the Centers for Disease Control, Atlanta, Georgia. Drug exposure data were taken from the National Survey of Drug Use and Health, with a response rate of 74.1%. Ethnicity and income data were taken from the US Census Bureau. National cannabinoid exposure was taken from Drug Enforcement Agency publications and multiplied by state cannabis use data to derive state-based estimates of Δ8THC exposure. At bivariate continuous analysis, Δ8THC was associated with 23 CAs on raw CA rates, 33 CARs after correction for early termination for anomaly estimates and 41 on a categorical analysis comparing the highest and lowest exposure quintiles. At inverse probability weighted multivariable additive and interactive models lagged to 0, 2 and 4 years, Δ8THC was linked with 39, 8, 4 and 9 CAs. Chromosomal, cardiovascular, gastrointestinal, genitourinary, limb, central nervous system (CNS) and face systems were particularly affected. The minimum E-values ranged to infinity. Both the number of anomalies implicated and the effect sizes demonstrated were much greater for Δ8THC than for tobacco and alcohol combined. Δ8THC appears epidemiologically to be more strongly associated with many CAs than for tobacco and alcohol and is consistent with a cannabinoid class genotoxic/epigenotoxic effect. Quantitative causality criteria were fulfilled, and causal relationships either for Δ8THC or for cannabinoid/s, for which it is a surrogate marker, may be in operation.

A "Good" Smoke? The Off-Label Use of Cannabidiol to Reduce Cannabis Use

BACKGROUND

Although cannabis use is common in France, it is still criminalized. Cannabidiol (CBD) products, including CBD-rich cannabis, are legally available. Although previous results suggested that CBD may have benefits for people with cannabis use disorder, there is a lack of data on cannabis users who use CBD to reduce their cannabis consumption. We aimed to identify (i) correlates of this motive, and (ii) factors associated with successful attempts to reduce cannabis use.

METHODS

A cross-sectional online survey among French-speaking CBD and cannabis users was conducted. Logistic regressions were performed to identify correlates of using CBD to reduce cannabis consumption and correlates of reporting a large reduction.

RESULTS

Eleven percent (n = 105) of our study sample reported they primarily used CBD to reduce cannabis consumption. Associated factors included smoking tobacco cigarettes (adjusted odds ratio (aOR) [95% confidence interval (CI)] 2.17 [1.3-3.62], p = 0.003) and drinking alcohol (aOR [95%CI] 1.8 [1.02-3.18], p = 0.042). Of these 105, 83% used CBD-rich cannabis to smoke, and 58.7% reported a large reduction in cannabis consumption. This large reduction was associated with non-daily cannabis use (aOR [95%CI] 7.14 [2.4-20.0], p < 0.001) and daily CBD use (aOR [95%CI] 5.87 [2.09-16.47], p = 0.001). A reduction in cannabis withdrawal symptoms thanks to CBD use was the most-cited effect at play in self-observed cannabis reduction.

CONCLUSIONS

Cannabis use reduction is a reported motive for CBD use-especially CBD-rich cannabis to smoke-in France. More studies are needed to explore practices associated with this motive and to accurately assess CBD effectiveness.

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

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

Cannabinoid Use Among Liver Transplant Recipients

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

Reasons for using cannabidiol: a cross-sectional study of French cannabidiol users

Background

Cannabidiol and cannabidiol-based products are proliferating in many countries. This recent and rapid diffusion prompts investigating the reasons for its use.

Methods

We analyzed data from an online survey among cannabidiol users in the French general population (n = 1166) selected for their interest in such products. We described the reported reasons for using cannabidiol. We performed logistic regressions to identify the correlates of declaring well-being and other specific reasons for using cannabidiol. We also provided descriptive data regarding the cannabidiol patterns of use.

Results

Well-being was the most cited primary reason for use (27% of the sample). Declaring well-being as a primary reason for using cannabidiol was inversely associated with cigarette smoking, cannabis use, and employment. Among cannabidiol users reporting well-being as their primary reason for use, stress and sleep improvements were the most-cited specific reasons. In the whole study sample, the most common modes of use were smoking cannabidiol-rich cannabis (61%) and ingesting cannabidiol oil sublingually (19%).

Conclusions

In a sample of cannabidiol users from France, well-being was the most-cited primary reason for use, and smoking was the first route of administration. Further research is needed to clarify to what extent expected effects are scientifically sound and to understand country-related specificities regarding patterns of use.

Selling cannabidiol products in Canada: A framing analysis of advertising claims by online retailers

Background

In Canada, the legalization of cannabis has enabled cannabidiol (CBD) to become a popular commercial product, increasingly used for medical or therapeutic purposes. There are currently over one thousand CBD products available globally, ranging from oil extracts to CBD-infused beverages. Despite increased usage and availability, the evidence supporting the medical efficacy of CBD is limited. Anecdotal evidence suggests CBD sellers represent their products for medical use through direct medical claims or advice, which in Canada, is not allowed under the Cannabis Act without Health Canada approval. However, it is not clear the extent of sellers making health claims or other strategies used to promote medical usage of CBD. The objective of this study is to determine how CBD sellers advertise their products online to consumers.

Methods

The product descriptions of 2165 CBD products from 70 websites selling CBD products for human consumption in Canada were collected from January 14th^, 2020 to February 2nd^, 2020 using an automated website scraper tool. A framing analysis was used to determine how CBD sellers frame their products to prospective customers. The specific medical conditions CBD is represented to treat and product forms were tabulated.

Results

CBD products are framed to prospective customer through three distinct frames: a specific cure or treatment (n = 1153), a natural health product (n = 872), and a product used in certain ways to achieve particular results (n = 1388). Product descriptions contained medical or therapeutic claims for 171 medical conditions and ailments, with 53.3% of products containing at least one claim. The most prevalent claims found in product descriptions were the ability to treat or manage pain (n = 824), anxiety (n = 609), and inflammation (n = 545). Claims were found for treating or managing serious and-life-threatening illnesses such as multiple sclerosis (n = 210), arthritis (n = 179), cancer (n = 169), Crohn’s disease (n = 78), Parkinson’s disease (n = 59), and human immunodeficiency virus (HIV) (n = 54). CBD most often came in oil/tincture/concentrate form (n = 755), followed by edibles (n = 428), and vaporizer pen/cartridge/liquid products (n = 290).

Conclusion

The findings suggest CBD is represented as a medical option for numerous conditions and ailments. We recommend Health Canada to conduct a systematic audit of companies selling CBD for regulatory adherence.

Health Claims About Cannabidiol Products: A Retrospective Analysis of U.S. Food and Drug Administration Warning Letters from 2015 to 2019

Background: Cannabidiol (CBD) products are increasingly available to consumers in the United States and are subject to regulation by the U.S. Food and Drug Administration (FDA). CBD products cannot be marketed as unapproved new drugs with claims of therapeutic benefit. In addition, because CBD is the active ingredient in a FDA-approved CBD product, Epidiolex, CBD cannot be marketed as, or in, food products or dietary supplements. The FDA has issued Warning Letters to promote voluntary regulatory compliance. These letters provide insights as to the types of violations for CBD products detected in the U.S. market. Objective: The goal of this retrospective study was to content analyze Warning Letters issued by the FDA to identify illicit marketing of CBD products. Design: Warning Letters issued by the FDA between 2015 and 2019 were content analyzed using a deductive approach. We extracted year of issuance, issuing office, and claim types that are currently prohibited by the FDA, including (i) unapproved new drug, (ii) misbranded drug, (iii) false and/or misleading, (iv) FDA-approved/endorsed, (v) dietary supplement, and (vi) adulterated food product. In addition, we documented the disease or conditions the product claimed to affect, pharmacological effects, and location of violation. Results: Of the 39 Warning Letters issued, 97% were for violations made on company websites and 56% were for social media accounts. Almost all letters (97%) cited violations of marketing CBD as an unapproved new drug. These illicit therapeutic claims were made for >125 unique health problems, including cancer (87.2%), diabetes (71.8%), inflammation (66.7%), pain (66.7%), and arthritis (66.7%). The majority of letters (79.5%) also cited illicit marketing of CBD as a dietary supplement or food product. CBD was promoted as having 16 unique pharmacological effects, including anti-inflammatory (53.8%), anticancer (43.6%), and antipsychotic (30.8%). Conclusions: CBD products have been unlawfully advertised online as unauthorized drugs with health claims that promote therapeutic benefits and as dietary supplements. Efforts are needed to regulate and monitor illicit advertising so consumers are not misled about the risks and benefits of CBD use.

Safety and Molecular-Toxicological Implications of Cannabidiol-Rich Cannabis Extract and Methylsulfonylmethane Co-Administration

Cannabidiol (CBD) is a biologically active, non-psychotropic component of Cannabis sativa whose popularity has grown exponentially in recent years. Besides a wealth of potential health benefits, ingestion of CBD poses risks for a number of side effects, of which hepatotoxicity and CBD/herb-drug interactions are of particular concern. Here, we investigated the interaction potential between the cannabidiol-rich cannabis extract (CRCE) and methylsulfonylmethane (MSM), a popular dietary supplement, in the mouse model. For this purpose, 8-week-old male C57BL6/J mice received MSM-containing water (80 mg/100 mL) ad libitum for 17 days. During the last three days of treatment, mice received three doses of CRCE administered in sesame oil via oral gavage (123 mg/kg/day). Administration of MSM alone did not result in any evidence of liver toxicity and did not induce expression of mouse cytochrome P450 (CYP) enzymes. Administration of CRCE did produce significant (p < 0.05) increases in Cyp1a2, Cyp2b10, Cyp2c29, Cyp3a4, Cyp3a11, Cyp2c65, and Cyp2c66 messenger RNA, however, this effect was not amplified by MSM/CRCE co-treatment. Similarly, no evidence of liver toxicity was observed in MSM/CRCE dosed mice. In conclusion, short-term MSM/CRCE co-administration did not demonstrate any evidence of hepatotoxicity in the mouse model.

Evidence for side effects of cannabidiol (CBD) products and their non-conformity on the European food market - response to the European Industrial Hemp Association

An interesting and valuable discussion has arisen from our recent article (Lachenmeier et al., 2020) and we are pleased to have the opportunity to expand on the various points we made. Equally important, we wish to correct several important misunderstandings that were made by Kruse and Beitzke (2020) on behalf of the European Industrial Hemp Association (EIHA) that possibly contributed to their concerns about the validity of our data, toxicological assessment and conclusions regarding regulatory status of cannabidiol (CBD) products. First and foremost, our study did only assess the risk of psychotropic Δ 9-tetrahydrocannabinol (THC) without inclusion of non-psychotropic Δ 9-tetrahydrocannabinolic acid (THCA). Secondly, as this article will discuss in more detail, there is ample evidence for side effects of CBD products, not only in paediatric patients, but also in adult users of over-the-counter CBD products (including inadvertent "high" effects). Thirdly, the exposure and risk assessment was conducted using up-to-date guidelines according to the European Food Safety Authority (EFSA) and the German Federal Institute for Risk Assessment (BfR). And finally, the current legal situation in the European Union, without approval of any hemp extract-containing product according to the Novel Food regulation, actually allows blanket statements that all such products are illegal on the market, and this indeed would imply a general ban on the use and marketing of such products as food or food ingredients until such an approval has been granted. We hope that this reassures the F1000Research readership regarding the validity of our results and conclusions. We are pleased, though, that the EIHA has acknowledged the fact that there are non-compliant CBD products available, but according to our data these are a substantial fraction of the market.

Evidence for adverse effects of cannabidiol (CBD) products and their non-conformity on the European food market - response to the European Industrial Hemp Association

An interesting and valuable discussion has arisen from our recent article (Lachenmeier et al., 2020) and we are pleased to have the opportunity to expand on the various points we made. Equally important, we wish to correct several important misunderstandings that were made by Kruse and Beitzke (2020) on behalf of the European Industrial Hemp Association (EIHA) that possibly contributed to their concerns about the validity of our data, toxicological assessment and conclusions regarding regulatory status of cannabidiol (CBD) products. First and foremost, our study did only assess the risk of psychotropic Δ 9-tetrahydrocannabinol (THC) without inclusion of non-psychotropic Δ 9-tetrahydrocannabinolic acid (THCA). Secondly, as this article will discuss in more detail, there is ample evidence for adverse effects of CBD products, not only in paediatric patients, but also in adult users of over-the-counter CBD products (including inadvertent "high" effects). Thirdly, the exposure and risk assessment was conducted using up-to-date guidelines according to the European Food Safety Authority (EFSA) and the German Federal Institute for Risk Assessment (BfR). And finally, the current legal situation in the European Union, without approval of any hemp extract-containing product according to the Novel Food regulation, actually allows blanket statements that all such products are illegal on the market, and this indeed would imply a general ban on the use and marketing of such products as food or food ingredients until such an approval has been granted. We hope that this reassures the F1000Research readership regarding the validity of our results and conclusions. We are pleased, though, that the EIHA has acknowledged the fact that there are non-compliant CBD products available, but according to our data these are a substantial fraction of the market.

Cannabidiol and Other Cannabinoids: From Toxicology and Pharmacology to the Development of a Regulatory Pathway

Cannabidiol (CBD) is a non-psychotropic constituent of Cannabis sativa that has grown in popularity during the last decade. CBD is the active component of EPIDIOLEX®, a U.S. Food and Drug Administration (FDA)-approved drug designed for the treatment of drug-resistant pediatric epileptic seizures associated with several rare syndromes. Furthermore, CBD has been proposed as a treatment for a number of other diseases for which clinical trials are now ongoing. Accumulating evidence indicates that the number of "CBD-containing" products, available mostly online, is growing exponentially. However, the U.S. FDA currently prohibits sales of CBD as a dietary supplement (DS) or ingredient in conventional food. Further, clear federal regulatory and quality oversight does not exist, which has led to an uncontrolled CBD market that, in turn, threatens to result in negative health effects experienced by a trusting public. Thus, there are open questions demanding answers in the very near future: For which medical purposes is CBD provably effective? Can it be used safely as a non-prescription product? At what level? Is a hemp extract that contains CBD a different ingredient than isolated CBD? Is CBD safe for everyone? What is a future path for hemp products with CBD as well as for other cannabinoids? Should CBD be allowed as a drug only, or is there a way for hemp extracts to be listed as a dietary supplement and food ingredient? This Special Issue, the first of its kind on CBD and other phytocannabinoids, is devoted to answering those and other questions by publishing articles in the fields of pharmacology, toxicology, and regulation.