CBD Hemp Oil For Pain: A Pharmacist’s Take

CBD hemp oil has become a more popular option to help treat or control different types of pain.

But because it comes from the marijuana plant there’s a lot of confusion and concerns over it’s use.

Because I talk to patients every day who are looking for options outside of narcotic pain killers I wanted to dig a bit deeper into the safety, effectiveness and legality of CBD.

What Exactly Is CBD Hemp Oil And
Will It Get You High?

Marijuana is a plant that basically has two parts:

  1. the flowers or ‘buds’ and
  2. the rest of the plant itself – i.e., the hemp plant.

Marijuana (buds and the rest of the plant) contains 113 cannabinoid compounds.

If you want to get ‘high’ you need the the flowers or buds because they contain high concentrations of one cannabinoid – THC (tetrahydrocannabinol).

The rest of the plant – or hemp – may contain very low amounts of THC but not enough to get you high. So it’s considered non-psycoactive.

The plant itself also contains many other cannabinoids. CBD (or cannabidiol) is one of them.

Unlike THC – CBD does NOT get you high.

Once CBD is in your system in can bind with cannabinoid receptors and other neurotransmitters in your body to produce it’s effects.

Bottom Line: THC is in the ingredient in marijuana that get’s you ‘high’ and comes from the flowers of the plant. Hemp is the rest of the plant – not the flowers. It can contain some THC – but very small amounts and not enough to get you high. But both the flowers and the hemp plant contain CBD which does not get you high and can help with treating pain.

How Does CBD Work?

A lot of people don’t realize that you actually have cannabinoid receptors in your body that CBD can bind to. This is called the Endocannabinoid System (ECS).

The ECS is involved in a lot of different functions in your body including appetite, fertility, memory, mood, pain and pregnancy.

With that being said – there are a number of different theories about how CBD works in your body but the bottom line is we really don’t know.

What Is The Best Way To Take It?

When it comes to CBD there are a couple of important points you need to remember:

  1. Bioavailability. That’s a fancy term for how fast and how much of a drug is absorbed into your bloodstream. You can take CBD a number of different ways and the bioavailability varies with all of them. With that being said ….
  2. There is not a lot of science behind most of the dosing recommendations. And the studies that have been performed have seen pretty wide fluctuations in bioavailability. Most of this is probably due to the fact that every person is different.

Here’s a quick breakdown of the estimates we have on CBD bioavailability in the body:

  • Oral (capsules, liquids and edibles): 4-20% bioavailable
  • Sublingual (tinctures, lozenges and sprays): 12-35% bioavailability [1]
  • Nasal Sprays: 34-46% [2]
  • Vaporized (vaping): 34-56% [3][4]

You Need To Also Consider
The Type Of Pain You’re Having

Just because something is more ‘bioavailable’ doesn’t mean it’s the best choice for you.

You also need to consider the type of pain you want to treat.

For example, there are reports that patients with chronic pain get better relief from oral CBD than any other form. The most popular theory out there is that CBD can be stored in fat cells and released over time.

The reports also point out that pain relief isn’t as quick either – which makes sense when you look at the bioavailability number.

If you have acute pain and need quicker relief you may want to consider some of the other methods like vaping or sublingual administration.

Both these methods avoid “first pass metablism”.

When you take drugs by mouth they have to go through your digestive system and your liver where they are broken down.

Vaping takes CBD directly into your lungs and then your bloodstream.

Sublingual get’s absorbed quickly via the mucus membranes.

While patient reports show that they act quicker – the effects don’t appear to last as long either.

What Dosage Should You Take?

For starters, talk to your doctor.

Secondly, much like the absorption issues with CBD and lack of studies there is no real hard set dosage recommendations for CBD in treating pain.

The most concrete recommendations I could find is from a site called Honest Marijuana where they have a small dosing chart based off weight and the severity of the pain you are treating.

Honest Marijuana CBD Dosage Calculator

The best advice I can give – and this really goes for any drug – is to find your minimum effective dosage and then move up from there.

And don’t rely on other people’s dosages.

For example, say you know someone who has taken CBD oil and recommends 20mg twice a day.

But you don’t know:

  • How long they’ve been taking it?
  • Have they built up a tolerance?
  • How healthy is their liver (for metablizing CBD)?
  • How much body fat do they have?

Again, start low and move up according to your body – not another person.

What Are The Side Effects?

CBD oil has been used at very high doses in other disease states before – as high as 20mg/kg/day.

In a 200 pound man that would be over 1,800 mg per day.

Overall, CBD appears to be well tolerated [5]

At the lower doses you would be using to treat pain I would not expect serious side effects. If they occur, the most common side effects are drowsiness and diarrhea.

Does It Work Better For Certain Types Of Pain?

There isn’t enough strong evidence that CBD oil would be better for specific types of pain. Although there have been positive studies conducted in arthritis [6] and chronic pain [7].

It’s also important to point out that when treating chronic pain researchers did notice an improvement in insomnia. So it may also help with sleep issues in that regard.

Is It Legal?

Since CBD is derived from hemp – which is derived from marijuana plants there’s constant change and uncertainty about what’s legal and what’s not.

Remember – CBD is not psychoactive. So it doesn’t cause any sort of ‘high’.

But according to the official ruling on CBD – and a team of attorneys for the US Government – CBD Hemp Oil is technically illegal.

According to DEA spokesperson Rusty Payne, “Hemp is a made up word. For it to be controlled, it has to fall within the definition of marijuana, not just test positive for THC. When it comes to CBD, these products are coming from the plant, which is controlled, which is illegal.”

And Michael Brubeck, CEO of Centura Natural Foods – a huge processor and supplier of CBD hemp oil, “It’s tolerated. It’s not being enforced. It is absolutely illegal, especially according to attorneys of the USDA, DOJ, DEA, and FDA.”

Even the behemoth Amazon does not carry CBD oil (they do carry hemp oil, however).

The confusing part is that if you live in a state where marijuana is legal you can get CBD oil. In fact, you can get CBD is just about anything – including your coffee and pet food.

However, there may be changes coming soon.

Mitch McConnell, the Republican Senate majority leader recently introduce the Hemp Farming Act of 2018. It’s purpose is to remove hemp from the DEA’s Controlled Substances Act – which would officially make CBD legal. A vote is scheduled for the fall of 2018.

How Does It Compare To Regular Pain Medications?

There isn’t any evidence looking at CBD versus prescription or OTC (over-the-counter) pain meds. So the verdict is still out on that.

Is It Safe To Take With My Other Medications?

When taken by mouth – CBD is metabolized by your liver and can cause some liver enzymes to work faster – and slow down or block others.

This means other medications that you are taking may be affected. Here is a list of drugs and their potential interactions:

  • Pletal (cilostazol) – CBD oil may increase cilostazol blood levels
  • Celexa (citalopram) – CBD oil may increase citalopram blood levels
  • Onfi (clobazam) – This is a well documented interaction. Clobazam blood levels can be increased. [8]
  • Plavix (clopidogrel) – CBD may cause blood levels of clopidigrel to be decreased.
  • Addyi (flibanserin) – blood levels of flibanserin may be INCREASED
  • Prograf (tacrolimus) – blood levels of tacrolimus may be INCREASED [9]
  • Depakote and others (valproate products) – CBD blood levels may be increased.
  • Coumadin (warfarin) – blood levels of warfarin can be INCREASED [10]

References:

  1. Kerri A. Schoedel and Sarah Jane Harrison. Current Pharmaceutical Design (2012) 18: 5008. https://doi.org/10.2174/138161212802884708 http://www.eurekaselect.com/102834/article
  2. Kalpana S. Paudel, Dana C. Hammell, Remigius U. Agu, Satyanarayana Valiveti & Audra L. Stinchcomb (2010) Cannabidiol bioavailability after nasal and transdermal application: effect of permeation enhancers, Drug Development and Industrial Pharmacy, 36:9, 1088-1097, DOI: 10.3109/03639041003657295 https://www.ncbi.nlm.nih.gov/pubmed/20545522
  3. Kalpana S. Paudel, Dana C. Hammell, Remigius U. Agu, Satyanarayana Valiveti & Audra L. Stinchcomb (2010) Cannabidiol bioavailability after nasal and transdermal application: effect of permeation enhancers, Drug Development and Industrial Pharmacy, 36:9, 1088-1097 https://www.ncbi.nlm.nih.gov/pubmed/20545522
  4. Huestis MA. Human Cannabinoid Pharmacokinetics. Chemistry & biodiversity. 2007;4(8):1770-1804. doi:10.1002/cbdv.200790152. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689518/
  5. Iffland K, Grotenhermen F. An Update on Safety and Side Effects of Cannabidiol: A Review of Clinical Data and Relevant Animal Studies. Cannabis and Cannabinoid Research. 2017;2(1):139-154. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569602/
  6. Hammell DC, Zhang LP, Ma F, et al. Transdermal cannabidiol reduces inflammation and pain-related behaviours in a rat model of arthritis. Eur J Pain. 2016;20(6):936-948.
  7. Russo EB. Cannabinoids in the management of difficult to treat pain. Therapeutics and Clinical Risk Management. 2008;4(1):245-259. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503660/
  8. Geffrey AL, Pollack SF, Bruno PL, Thiele EA. Drug-drug interaction between clobazam and cannabidiol in children with refractory epilepsy. Epilepsia. 2015;56(8):1246-1251.
  9. Leino A, Emoto C, Fukuda T, Privitera M, Vinks A, Alloway R. Evidence of a clinically significant drug-drug interaction between cannabidiol and tacrolimus: A case report [abstract]. 2018 Meeting of American Transplant Congress; June 3, 2018; Cincinnati, OH. Abstract B331.
  10. Grayson L, Vines B, Nichol K, Szaflarski JP; UAB CBD Program. An interaction between warfarin and cannabidiol, a case report. Epilepsy Behav Case Rep. 2017;9:10-11.