The potential benefits of cannabidiol (CBD) have been discussed in various medical forums throughout the United States, but what is the truth surrounding this compound? Medical claims have suggested beneficial outcomes from the use of CBD in several diseases and conditions, such as epilepsy, anxiety and pain control. Probably the most well-known story is that of a young girl named Charlotte Figi, who had Dravet syndrome and suffered up to 300 grand mal seizures a week.1
After finding some success in treating their daughter’s illness with a type of marijuana high in CBD and low in tetrahydrocannabinol (THC), Charlotte’s parents, Matt and Paige Figi, sought out the Stanley brothers, Colorado dispensary owners who were growing a type of hybrid plant that had a consistent 30-1 CBD-to-THC ratio. The product mix of industrial hemp high in CBD content helped Charlotte become seizure free. That special strain is now known as Charlotte’s Web and has put the medicinal use of the plant in the spotlight throughout the United States and the world.
Pharmacists and Cannabinoids
As pharmacists, we take an oath to be medication experts who provide patients with pharmaceutical information on the safe and effective use of their drugs. We accept the lifelong obligation to improve our professional knowledge and competence, and we adopt evidence-based practices as the cornerstone of our decision-making. However, CBD has not followed the same path that a normal pharmaceutical product does to receive FDA approval. Cannabinoids have been listed as schedule I narcotics for more than 60 years. By definition, a schedule I narcotic has no direct therapeutic benefit, and its claim as a pharmacological agent has no validation.
However, more than half of U.S. states have either a recreational or medicinal program in place to provide patients with these compounds for administration. We now see the public engaging with pharmacists to answer some of the questions regarding the safety and efficacy of cannabinoids, primarily CBD. Before we get into details regarding CBD, we first need to discuss the mechanism of action for these agents.
Endocannabinoids and Phytocannabinoids
The human body produces its own cannabinoids in the form of endocannabinoids, known as N-arachidonoylethanolamine (anandamide) and 2-arachidonoylglycerol. The phytocannabinoids are cannabis-based compounds representing more than 700 chemicals, and more than 200 distant phytocannabinoids have been identi ed. In addition to THC and CBD, the primary families are cannabichromene and cannabigerol.
The endocannabinoid system is a complex regulatory system that directly influences processes such as memory, digestion, immune response and motor function. The discovery of the endocannabinoid system within our bodies was predicated on the discovery of THC in the late 1980s. Soon after, CBD was found to bind to a CB1 receptor in the body, producing physiological effects.2
Most of the preclinical studies and data on CBD are found in animal model testing because the traditional methods involving standard drug development processes — such as preclinical, phase I, II and III testing that forms Food and Drug Administration (FDA) approvals—are lacking. The National Academies of Sciences, Engineering, and Medicine formed a committee to collaborate on a review and provide independent, objective analysis and advice to the nation regarding various health topics related to CBD. The committee examined literature in 21 therapeutic categories published up to 2017. Their findings suggested that3:
• For adults with chemotherapy-induced nausea and vomiting, oral cannabinoids are effective antiemetics.
• Adult patients with chronic pain who are treated with cannabis or cannabinoids are more likely to experience a clinically significant reduction in pain symptoms.
For these conditions, the effects of cannabinoids are modest, but there is inadequate information to assess their effects for all other evaluated conditions. However, the anecdotal stories of the therapeutic successes of these medications in patients keep the pharmaceutical community engaged about the possibilities.
Only recently, GW Pharma obtained FDA approval for the cannabinoid compound Epidiolex for the treatment of two rare forms of epilepsy in patients 2 years and older.
Opportunities in Pharmacy
Could the prevalence of CBD be an opportunity for pharmacists to educate the patient population and potentially sell these products in their stores? The answer to both questions is yes. However, due diligence needs to be followed by pharmacists, with a full understanding of what these compounds truly present in terms of both safety and ef cacy. Some states with medicinal and recreational programs involve pharmacies as a mandate for dispensing, and some do not. Do we as a profession embrace the potential of this widely emerging treatment for patients?
Pharmacists need a better understanding of these products as well as educational programs regarding state and federal laws for the sale of CBD products. Are all CBD products the same? What’s the difference between the various extraction processes? What is the entourage effect, and what are terpenes good for? What does the passage of the federal Farm Bill mean for pharmacists and patients? Is the same product that is sold in convenience stores and local gas stations the same as what is sold in pharmacies? How do the FDA, the Drug Enforcement Administration and the National Institute on Drug Abuse classify CBD and other cannabinoids?
In future issues, Total PharmacyTM will embark on a series of educational articles to answer some of the questions regarding the CBD market and discuss opportunities that may be available to practicing pharmacists and store owners.
Jeff Lombardo, Pharm.D., is a research assistant professor at the Center for Integrated Global Biomedical Sciences, Translational Pharmacology Research Core, at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences in New York.