I live in Denver, Colorado and since the legalization of recreational marijuana in 2014, I have witnessed an explosion of the industry with cannabis dispensaries popping up on most major city blocks. One cannabis-based product that is garnering great attention is cannabidiol (CBD) oil to treat anxiety, insomnia, joint pain, inflammation and depression (Hilderbrand, 2018). The oil is often administered as drops sublingually and has also been added to products (lotions, sports creams, balms), beverages (infused water, coffee) and food (jams, gummies). What exactly is CBD oil and how is it different from cannabis?

Background (Hill, 2015; Pressman & Clemens, 2019)

Marijuana (cannabis sativa) has been in use for centuries. The Chinese found over a hundred medicinal applications for marijuana by 100 AD. Ancient Egyptians and Greeks both used marijuana to treat conditions such as glaucoma, inflammation, and swelling. In the early 1900’s, marijuana was an ingredient in several medications and administered as a pain killer, sedative, and treatment for muscle spasm. It was during this time that recreational use was introduced and by the 1930’s several states began regulating the drug. Cannabis was defined as a Schedule I substance by the Federal Controlled Substance Act of 1970 for its high potential to cause abuse and addiction and the lack of a proven medical use at that time (Federal Drug Administration [FDA], 2019). Today there are approximately 35 million regular users (more than twice a month) in the United States, making it the most commonly used illicit drug.

Cannabis can be inhaled, taken orally, sublingually, and topically. While research is limited, medicinal cannabis has been used to treat chemotherapy-induced nausea and vomiting, cancer-associated anorexia, irritable bowel syndrome, chronic pain, multiple sclerosis, epilepsy, amyotrophic lateral sclerosis, Parkinson’s disease, addiction and schizophrenia (Khalil, 2018; O’Malley, 2019). The California Compassionate Use Act in 1996 was the first state law to legalize the use of cannabis for pain relief and to mitigate emesis in patients with AIDS (O’Malley, 2019). Unlike the street version, medicinal cannabis must be tested for quality, labeled by the grower, and verified by an independent third party for the active ingredients cannabinoids (CB).

Cannabis contains over 100 varieties of CBs which interact with the body’s endocannabinoid system in distinct ways (Khalil, 2018). The most common CBs are delta-9 tetrahydrocannabinol (THC), cannabidiol (CBD), and cannabinol (CBN). THC is the natural component that binds with CB 1 receptors located in the brain and nervous system causing euphoria and other psychoactive effects. CBN is mildly psychoactive and has a higher affinity to CB 2 receptors found in the immune system (Khalil, 2018). CBD barely binds to CB receptors, if at all, but may interfere with THC activity resulting in a diminished psychoactive effect. While CBD and THC have the same molecular make up (21 carbon atoms, 30 hydrogen atoms and 2 oxygen atoms), they are arranged in a different structure (World Health Organization [WHO], 2017) which may account for their opposing mechanisms.

The following table summarizes the differences between CBD and Cannabis/THC:
 

CBD versus Cannabis/THC (FDA, 2019; WHO, 2017)
	CBD	THC
Botanical source	Hemp has a higher concentration of CBC but may contain THC (less than 3%)	Cannabis/marijuana has a higher concentration of THC
Effect on endocannabinoid system	May bind to CB receptors minimally, if at all; may also interfere with THC binding	Bind to CB 1 receptors in the brain and nervous system affecting pain, immune function, stress, and sleep
Cause psychoactive effects or “high”	No	Yes
Cause physical dependence	No	Yes
Medical Uses	Seizures Inflammation Pain Psychosis or mental disorders Nausea Migraines Depression Anxiety	Inflammation Pain Muscle spasticity Glaucoma Insomnia Low appetite Nausea Anxiety
Side Effects	Well tolerated; side effects typically caused by drug interactions. See below for adverse effects associated with FDA-approved, CBD-based drugs.	Temporary side effects include: Tachycardia Decreased coordination Dry mouth Red eyes Slow reaction time Memory loss
Drug Testing	Stored in adipose tissue and may show up on drug tests for several days or weeks after use. Not all tests are sensitive to CBD, but CBD-specific tests are available. Hemp may produce some THC which may cause a false positive result.	Stored in adipose tissue and may show up on drug tests for several days or weeks after use.
Legal	Legal in states that have legalized recreational marijuana. Cannot contain more than 0.3% THC to be sold legally. Remains illegal at the federal level.	Legal in states that have legalized medical and recreational marijuana; prescription is required for medical use. Remains illegal at the federal level.

FDA-Approved Cannabis Drugs (FDA, 2019)

There are four cannabinoid-based drugs approved by the FDA and on the market today: three synthetic compounds including Marinol, Syndros, and Cesamet as well as one purified form, Epidiolex. Marinol and Syndros contain a synthetic THC called dronabinol and are used to treat weight loss secondary to acquired immunodeficiency syndrome, and chemotherapy-induced nausea. Cesamet contains nabilone and is also used to treat chemotherapy-induced nausea and vomiting. Epidiolex is the first purified drug from marijuana to be approved by the FDA to treat two rare types of pediatric seizure disorders, Lennox-Gastaut syndrome and Dravet syndrome. Side effects include somnolence, elevated liver enzymes, decreased appetite, diarrhea, rash, fatigue, malaise, weakness, insomnia, sleep disorder, poor quality sleep and infections (Pressman & Clemens, 2019). Baseline liver function tests (LFTs) should be collected and reviewed before beginning therapy and then repeated after one, three, and six months of treatment. Assess the patient for signs and symptoms of liver disease including nausea, vomiting, right upper abdominal pain, fatigue, anorexia, jaundice, and dark urine (Pressman & Clemens, 2019). Patients should be educated to use the measuring device that is included in the packaging.

The marijuana industry is rapidly expanding as the trend toward legalization continues. There are a multitude of CBD products on the market that claim to have therapeutic value but are not FDA approved. Nurses should have a fundamental knowledge of both approved and non-approved cannabis-based products and their effects in order to properly educate and effectively manage their patients.
 

References:
Food and Drug Administration (2019). FDA Regulation of Cannabis and Cannabis-Derived Products: Questions and Answers. Retrieved from https://www.fda.gov/news-events/public-health-focus/fda-regulation-cannabis-and-cannabis-derived-products-questions-and-answers#approved

Hilderbrand, R.L. (2018). Hemp & cannabidiol: What is a medicine? Missouri Medicine. 115(4), 306-309.
Hill, K. (2015). Marijuana: The unbiased truth about the world’s most popular weed. Center City, Minnesota: Hazelden Publishing.

Khalil, H. (2018). Medicinal cannabis: presenting possible treatment modalities for the future. International Journal of Evident-based Healthcare.

O’Malley, P. A. (2019). Therapeutic and recreational marijuana – Safe practice within the web of politics, science, law, and nursing. Clinical Nurse Specialist. X(X), 110-113.

Pressman, P. & Clemens, R. (2019). Introduction: Cannabis in society today. Nutrition Today. 54(2), 78-83.
World Health Organization (2017). Cannabidiol (CBD) Pre-Review Report. Retrieved from https://www.who.int/medicines/access/controlled-substances/5.2_CBD.pdf