There hardly seems to be a day when cannabis-based medicines haven’t featured in the media in some way…
CBD: All you need to know
From the recent high-profile case of thirteen- year-old Billy Caldwell, who was denied legal access to the cannabis oil that helps to control his epileptic seizures, to various studies that have shown that cannabinoid (CBD) treatments can help a wide range of ills, from anxiety to epilepsy, from inflammation to pain – the subject of cannabis-based medicines has not only dominated the headlines, but has certainly divided opinion.
Why is this?
well, cannabinoids are the chemicals which are found naturally in marijuana plants. Even though they come from marijuana plants, however, cannabinoids don’t create any form of ‘high’ or any form of intoxication- that is caused by another cannabinoid known as THC. (Billy Caldwell’s medicine, for example, was illegal because it contained THC, the psychoactive compound that affects those who smoke cannabis.)
These new treatments, however, use the less mind-bending cannabinoid known as CBD.
CBD is extracted from marijuana plants in either oil or powder format. it can be mixed into creams or gels and can then be put into capsules and taken orally, or rubbed onto the skin in topical format.
What is it used for?
Anxiety relief: researchers think that CBD may be able to help patients manage anxiety because it has the potential to change the way that the brain’s receptors respond to serotonin, a chemical that is primarily linked to mental health. One recent study, for example, found that a 600mg dose of CDB helped people who suffered from social anxiety to speak in public.
Prevention or reduction of seizures: the case of Billy Caldwell highlighted the fact that CBD may be a possible treatment for epilepsy. A study carried out in 2016 involved more than 200 people with epilepsy who, until the study, had been given anti-epilepsy medications. For the study, they were given an additional oral dose of 2-5mg of CBD. After twelve weeks of monitoring, participants had 36.5 fewer seizures per month, which was very positive news, but, conversely, severe adverse effects were recorded in twelve per cent of the study group.
Treatment of acne: it’s thought that CBD oil may prevent activity in sebaceous glands – the glands, which are responsible for producing sebum, overproduction of which can lead to acne.
Pain relief: inflammation is behind many patients’ pain issues and so researchers think that the effects of CBD oil on the brains receptors may help patients to manage their pain.
Neuroprotective: at present, researchers are currently looking at two types of cannabinoid receptor with regard to possible treatment of pharmacological treatment of disease. These receptors are CB1 and CB2 and both have wide expression through the central nervous and immune systems. CB1 receptors are attached to THC, forming a psychoactive effect, while CB2 receptors are attached to CBD, providing an immunomodulatory and pain suppression effect.
What’s available at the minute?
At the moment there are only two cannabis-based pharmaceutical drugs, which are manufactured in the UK and which are licensed for prescription, but only for very specific uses. Sativex has been used in the UK since 2010 to treat spasticity in multiple sclerosis and uses THC and CBD in a 50:50 ratio.
A new CBD-drug only rug, Epidiolex, meanwhile, was approved in June in the USA to treat rare childhood epilepsies and it is expected that similar approval will be granted soon in the UK.
Difficulties/challenges presented by cannabis-based products
Simply put, the main problem regarding these products is that, while there is a lot of research being carried out in the treatment of many different conditions, most of it is in the early stages and so most of the evaluation and evidence is currently, at best, theoretical.
Pain management is an excellent example of the current confusion. At present, for example, there are no cannabis-based products routinely commissioned for use, and both the Faculty of Pain Medicine and the British Pain Society support the view that further research is required to evaluate the safety, efficacy and harms of cannabis-based preparations in pain management. Specialists are also awaiting NICE guidelines to support the prescribing of cannabis-based products. This is expected by October 2019.
Healthcare professionals also recommend that patients should not be referred to secondary care for cannabis-based products for pain due to the lack of good evidence associated with their use and the risk of adverse effect. This includes neuropathic, non-malignant and cancer pain.
So, where does that leave the Pharmacist?
After all, since cannabinoid treatments are now available in the UK in everything from skin creams to beers, it is the pharmacist that many patients will look to for advice and information.
There is no doubt that, in the current climate of few evidence-based outcomes and evaluation that is simply theoretical, the pharmacist is still the best source of information with regard to these products.
While CBD is available from many outlets, while uncertainty exists with regard to contraindications etc, the pharmacist is best placed to make suggestions to patients based on pharmaceutical and clinical evidence. With media interest in CBD high at the moment, many patients are going to the pharmacy looking for ‘wonder cures’ for pain etc based on newspaper and magazine articles. While pharmacists can certainly suggest that patients try such products in a rational and controlled manner, the interventions and consultations can provide the pharmacist with the opportunity to both advise on possible contraindications and also to have a general discussion on lifestyle and well-being advice that may help the patient with their particular healthcare issue.
The direction of travel for pharmacies has to be into spearheading an informed and well-controlled, evidence-based treatment approach in a Clinical setting.