The Empowered Pain Patient’s Guide to CBD
What can CBD (aka: cannabidiol) do for your chronic pain? This natural compound extracted from the Cannabis sativa plant will not get you high, since it does not produce the same psychotropic effects as its cannabinoid sibling, tetrahydrocannabinol (THC), but many people are finding that it can complement their pain care plan. In fact, research shows that of the 62% of people who use CBD for a medical condition, the majority are treating chronic pain, arthritis, and joint pain, as well as anxiety.
What’s more, CBD has minimal side effects and a low-risk, zero-addiction profile. But before you pop a gummy or ingest an oil, you’ll want to read on.
SO, WHAT IS CBD EXACTLY?
Yes, cannabidiol (CBD) does come from marijuana. But let’s say it again and louder for the people in the back: No, it does not get you high! In the United States, legal CBD products are predominantly derived from the hemp plant, which is a species of the sativa marijuana plant. A key difference is that hemp contains 0.3% or less of THC cannabinoids.
CBD is legal – at the federal level (kind of), and in most but not all states (more on this later).
When we talk about CBD, we are typically talking about CBD products, such as topical creams and ingestible oils that are created by extracting the CBD compound from the marijuana plant. Although, some CBD products do contain small amounts of THC – which we will get to.
CBD has been shown to be:
- anti-inflammatory, meaning it has potential to reduce joint pain associated with arthritis
- anti-oxidative, so it may reduce systematic inflammation by fighting oxidative stress and decrease symptoms of autoimmune conditions like lupus
- anti-emetic, meaning it can decrease vomiting and nausea associated with cancer treatments
- anti-psychotic, so it can ease symptoms of anxiety and post-traumatic stress disorder (PTSD)
- neuroprotective, meaning it may help to slow the progression of neurological disorders such as Multiple Sclerosis (MS).
Specific conditions that may be helped by CBD include:
Irritable Bowel Syndrome
Multiple Sclerosis (MS)
Post-Traumatic Stress Disorder (PTSD)
BUT WAIT, CBD GETS COMPLICATED: HERE’s HOW IT DIFFERS FROM MEDICAL MARIJUANA AND HEMP
Is CBD Actually Marijuana or Hemp, or Both?
Let’s break it down:
- CBD is a cannabinoid found in marijuana plants that has many beneficial effects, without the psychotropic effects of its cannabinoid counterpart, THC.
- CBD can be derived from various varieties of the marijuana plant including both sativa and indica.
- Hemp is a species of the sativa marijuana varietal plant and has some unique features:
– Won’t get you high
– Contains 0.3% or less THC
– Has limited chemical compounds
– Is used to makes clothes and textiles
– Is legally sold in many stores and online
- CBD derived from hemp is legal at the federal level. CBD derived from non-hemp marijuana is not legal at the federal level but is legal in certain states.
- CBD derived from hemp may lack certain compounds that some research suggests aids in medicinal benefits, something referred to as the entourage effect (we’ll dive into this shortly).
Just How Legal is CBD?
The 2018 US Farm Bill legalized the growing of hemp and sale of hemp-derived products, which made CBD legal at the federal level (mostly). As noted, hemp is a species of the marijuana plant with one very important distinction: the variety must have less than 0.3% THC. So, if the CBD you buy comes from a hemp plant with less than 0.3% CBD and is grown in accordance with the 2018 Farm Bill regulations, and you live in a state where CBD is legal, you are in full abidance of the law.
The CBD compound itself is still classified as Schedule I drug (along with LSD and heroin). Federally, CBD derived from non-hemp marijuana is illegal. If you live in a state that has legalized marijuana, you can find non-hemp derived CBD products at a medical marijuana dispensary.
What about all those CBD products you’re seeing in line at the supermarket, the local health food store, and online? The market for CBD has basically exploded in the past few years but is completely unregulated. The CBD you buy may come from hemp or may not. It may contain the amount of CBD it claims or may not. It also may contain more THC than it claims. Welcome to the budding world (pun intended) of medicinal CBD.
Here’s the bottom line: CBD products that come from the hemp plant (meaning the THC level does not go above 0.3%) are legal across the country. CBD products that come from non-hemp marijuana (meaning the THC levels may go above 0.3%) may be legal depending on the state you live in but are not legal at the federal level.
THE SCIENCE BEHIND CBD: HOW IT WORKS FOR PAIN AND PAIN-RELATED SYMPTOMS
Your Natural Endocannabinoid System Supports CBD
Our body’s endocannabinoid system is composed of three main components:
- Cannabinoid receptors, namely CB1 and CB2. CB1 receptors are predominantly found in the central nervous system (CNS, the nerves attached along the spinal cord and around the brain) and are largely responsible for the cognitive and emotional effects of marijuana, as well as our perception of pain. CB2 receptors are more common in our peripheral nervous system (PNS, the outer nerves beyond the spinal cord and brain such as those in your arms and legs, although these receptors may also be found in our CNS) and in your immune cells.
- Endogenous cannabinoids (the cannabinoids that your body produces)
- Enzymes that facilitate the breakdown and use of cannabinoids
Our natural endocannabinoids function on demand, meaning that when our body senses inflammation, or needs to return to homeostasis (a state of stable balance) it will release endocannabinoids that bind to cannabinoid receptors.
CBD itself does not bind to receptors but is thought to work by inducing other components of the cannabinoid system.
In fact, CBD exerts a wide array of effects on the body’s central and peripheral nervous systems, as well as the immune system. It works in conjunction with our endocannabinoid system to function in an antioxidant capacity, to decrease inflammation, and to act as an analgesic or pain reliever. CBD may even slow the progression of osteoarthritis and prevent nerve damage, according to early model studies.
Your Body Chemistry Matters
Because of the way the endocannabinoid system works, the bioavailability of CBD is an important factor in how you will respond. Bioavailability is the amount of a substance that successfully makes it into the bloodstream and has an effect. Think about how some medications require you to take them with food or water, or on an empty stomach. Well, the amount of CBD that you actually absorb when taking a CBD product works the same way and will depend on:
- The form you take: For example, CBD edibles may be better absorbed when taken with food, especially fatty foods. See all the types of CBD products listed below.
- Your weight and marijuana history: Like any medication or supplement, you may want to take CBD according to your weight. However, two people of the same gender and weight may respond very differently to the same dosage due to factors such as metabolism, body composition, and history of using marijuana products. A good rule of thumb is to begin with a small dose such as 2 mg and increase by 2 to 5 mg after a period of weeks. The product you choose will also matter. For example, edibles take a longer time for your body to process and you may not feel their effects for hours. In the case of edibles, it is best to choose 1 dose per attempt, and not take more unless you do not feel the effects after 3 to 4 full hours.
- Your habits: Whether you’ve eaten, slept, or are stressed can all affect how your body responds to taking CBD.
CBD’s Potential Benefits
Importantly, CBD is hydrophobic and lipophilic, meaning it will dissolve in fats. The dissolution helps it to be carried across the blood-brain barrier and affect your CNS, where it can have a broad range of positive effects on pain including:
- Reducing Pain Signals – CBD modulates pain and the sensation of pain by stimulating the reuptake of the neurotransmitter, adenosine, thereby boosting adenosine levels in the brain and inhibiting pain sensations. CBD may also block pain signals from reaching processing centers in the brain by binding to TPRV1, which is responsible for pain and inflammation.
- Increasing Immune Response – CBD can modulate the immune response by decreasing levels of pro-inflammatory cytokines and inhibits the proliferation of T cells that are indicated in autoimmune and systemic inflammatory disorders.
- Reducing Inflammation – CBD decreases oxidative stress and systemic inflammation by acting as an antioxidant. CBD may also decrease inflammation by preventing a reductions in micro elements like zinc and selenium, which are important actors for a balanced immune response, and may reduce neuropathic pain (such as fibromyalgia or neuropathic back pain) by countering hyperalgesia (an abnormally heightened pain response).
- Improving Mood and Sleep – Chronic pain can disrupt your daily life, relationships, work, and mental health. If you are facing anxiety, depression, insomnia, and fatigue – all common with chronic pain – CBD may help you relax or get the restful sleep you need. Note, however, that many studies that relate CBD to improved sleep focus on full spectrum CBD (described below) and it is thought that the entourage effect of THC (along with terpenes and other cannabinoids) is mainly responsible for aiding in sleep.
Given these benefits, CBD is thought to be helpful in easing the symptoms of the following conditions:
- Osteoarthritis – this painful joint condition has been examined quite a bit in relation to CBD. Some early studies show that CBD acts as an antagonist and blocks or debilitates the GPR55 receptor, which may slow osteoarthritis by facilitating bone reabsorption.
- Type 2 Diabetes – CBD may activate a receptor called, PPAR-gamma, which may increase insulin sensitivity, an important step in improving type 2 diabetes, and decreasing the risk for developing diabetes-related neuropathic pain.
- Cancer and Alzheimer’s – CBD may exert an anti-cancer effect via the debilitation of GPR55 receptors in the body and by the activation of the PPAR-gamma receptor, which also degrades amyloid-beta plaque, a key molecule linked to the development of Alzheimer’s disease.
- Lupus and Rheumatoid Arthritis – CBD continues to be studied for these inflammatory and autoimmune conditions, as well as for fibromyalgia. Here’s more on cannabinoids and lupus.
- Multiple Sclerosis – there are mixed data for the use of CBD (as well as THC) in helping to reduce MS-related pain and spasticity.
- Anxiety – as noted, anxiety related to living with chronic pain, or that exists on its own, may be eased with CBD use, whether temporarily or in the long-term.
Keep in mind that while CBD can have many benefits, it is not a cure-all and should not be viewed as an alternative to your other pain care treatments. Rather, CBD should be considered a complementary treatment to add to your pain management toolbox.
HOW TO USE CBD FOR PAIN: WHICH PRODUCTS TO TRY
The (i)llegality surrounding CBD and medicinal marijuana (which are a whole other category, described in our medical marijuana for pain guide) can make choosing and using the right product confusing. Here is what you may find when you start searching the marketplace.
Get to Know the CBD Isolate, Broad, and Full Spectrum Products
Scientists are still discovering the different ways in which CBD may help to fight disease and reduce pain and its related symptoms. They are also still working to understand the functionality of CBD as an isolated compound versus a whole plant. For example, you may come across product descriptions such as CBD isolate, Full Spectrum CBD, and Broad Spectrum CBD.
Here’s a quick cheat sheet but note that efficacy of each is still up for debate.
A CBD isolate refers to a product that is composed of the CBD compound only and is extracted from the marijuana plant. CBD isolates can be extracted from both hemp and non-hemp species of marijuana. Remember, for it to be federally legal, it must come from the hemp species. In states where medicinal marijuana is legal, you can find CBD isolates in a marijuana dispensary. Additionally, certain CBD isolates are synthetic forms, such as those used in the pharmaceuticals Marinol and Syndros – both FDA approved to relieve chemotherapy-induced nausea and to improve appetite in people with AIDS.
Full Spectrum CBD products maintain the full profile of the marijuana plant and in addition to CBD, contain a variety of other cannabinoids including: THC, CBDa, CBG, and CBN, as well as terpenes and other compounds such as flavonoids, proteins, phenols, sterols, and esters. Technically, full spectrum products can contain 0.3% or less THC, if they are derived from the hemp species, however, full spectrum CBD products derived from non-hemp marijuana tend to have a wider cannabinoid and terpene profile.
Broad Spectrum cannabis products maintain the whole profile of the marijuana plant, but with the THC mostly removed.
Be Aware of the Entourage Effect
Proponents of full spectrum cannabis products refer to something called the entourage effect, which basically means that the compounds in marijuana work synergistically or cooperatively. Think of marijuana like a plant (which it is). Just like vitamin supplements don’t offer the same benefits as consuming whole foods, CBD isolates may not offer the same benefits as whole-plant extracts.
But it’s not that simple. CBD has been shown to decrease the psychotropic effects of THC, meaning that if a full spectrum extract has a greater ratio of THC to CBD, you won’t necessarily feel so high. Of course, everyone responds differently to marijuana and this will involve a lot of trial and error.
Although CBD is generally well tolerated, THC may decrease potential side effects of CBD. THC may also play an important role in CBD’s pain-relieving effects, by aiding its influence on the endocannabinoid system.
The entourage effect also accounts for the terpenes that can differ between various strains of marijuana and contribute to the plant’s effect. Some recent research points to the beneficial effects of this compound (think aromatherapy).
To top it off, the entourage effect may further offer benefits that a CBD isolate doesn’t, but CBD isolates can still offer many medicinal benefits, especially when applied topically for pain conditions.
Clear? You likely still have questions. Read on for specific products and which symptoms they aid.
Choose a CBD Product that Fits Your Needs
Selecting a CBD product depends on:
- The pain you are experiencing
- The effect you are seeking, such as how quickly it will take effect after you use/apply the CBD, and how long that effect lasts
- Personal preference for administration
A budtender – that’s what they call dispensary pharmacists – or your doctor can guide you, but here’s a quick overview.
Topicals include CBD creams, lotions, salves, and ointments. These are usually best to treat localized pain, arthritic pain, and neuropathic or nerve pain. Applied directly to the skin, one advantage of topicals is that they do not seem to exert any psychotropic effects. Studies have shown potential benefit of topicals in the treatment of arthritic pain in particular.
Ingesting CBD can be more beneficial for people with systemic inflammatory conditions (such as rheumatoid arthritis or Multiple Sclerosis [MS]), autoimmune conditions, and full body pain, caused by neurological conditions such as fibromyalgia or cancer pain.
Because CBD dissolves in fats, it’s a good idea to choose products that have healthy oils, to increase absorption rates.
Oral ingestions come in many forms such as:
- CBD isolate oral sprays that are taken under the tongue and rapidly absorbed into the bloodstream. With oral sprays and tinctures, it is generally easier to control the dose.
- Capsules are essentially a pill form of CBD. You might want to take them with a snack high in healthy fats to increase the bioavailability of the CBD.
- Oils come in a variety of products and are typically a combination of CBD extract and a plant-based oil. You can take these directly under the tongue or add them to food products.
- Edibles are oral products that you consume like any food product – think CBD brownies, gummies, and snacks. While the passage of CBD edibles through the digestive tract makes the effect more difficult to predict, it may have specific immunosuppressive benefits for people with MS and other autoimmune conditions. This effect is likely due to the interaction of CBD with the plethora of immune cells in our intestinal lymphatic system.
Vaping has become a popular form of taking CBD. Unlike rolling a joint, vaping involves a CBD oil cartridge that is inserted into a vaping pen. While some may assume that vaping is safer than smoking, there are dangers associated with both practices regarding lung health.
You can vape a full spectrum CBD, which may get you a bit high, even when using a strain with trace amounts of THC.
You can also vape a CBD isolate or broad spectrum oil, which should not induce a high.
How to Buy a CBD Product
First, consider the source. Studies show that continuous CBD consumption is generally safe and can have many benefits. However, because of CBD’s complicated status, the compound itself may still be classified as an illegal substance. See the FDA’s FAQs on cannabis regulations (#9).
How do you know you are getting the CBD the package claims? You don’t, but there are a few ways to put the odds in your favor.
- Buy direct from the manufacturer, either online or in the store.
- Look for brands based in early legalization states, such as Colorado, Washington, and Oregon.
- Look for organic sourcing (theUS Dept of Agriculture can certify CBD products as organic. Additionally, some clinicians recommend that patients utilize CBD products imported from Europe, which actually has even more stringent requirements for low THC levels (< 0.2%) as well as a more established regulatory system for hemp.)
These tips and tricks may help ensure your CBD is the real deal, but they still don’t provide proof. The best way to be sure you are consuming what you want is to request third party testing. Some products will print a QR code on the packaging that links directly to their proof of third-party testing. You can also do your own third-party testing by bringing your CBD sample to a testing lab, although this may get a bit tedious (the USDA provides a searchable hemp testing laboratory list).
These days, it seems like you can purchase CBD just about anywhere, but if it’s an option, you may want to visit a medical marijuana dispensary. Buying CDB from a medical dispensary doesn’t guarantee the product’s quality but it’s a good place to start. Before you go:
- Make a specific list of your pain symptoms and if possible, share the source of the pain (eg, an injury, a specific condition).
- Have an idea of how much THC you want in your product. Remember the ratio of THC to CBD has a lot to do with how much of a high the product will give you. It will also help determine how the product functions (our medical marijuana guide reviews CBD:THC ratios).
- Understand that CBD use requires a lot of touch and go to find benefit. You may want to buy smaller amounts of different varieties first and keep a journal on how much you took, what type, and how it affected you so that you can share that information with the dispensary budtender next time.
- Educate yourself on different products and strains (Green Leaf provides some examples of strains.)
WHAT ELSE TO EXPECT WHEN TAKING CBD
OK, so we know that taking it won’t get you high, but taking enough (often based on your weight), can have a calming effect. And the side effects are minimal, with some people experiencing drowsiness, nausea, or tiredness. It is unlikely to negatively impact your mood or cognitive ability, making it a seemingly safer and preferred product for many.
But it is important to be cautious if you are taking other medications or substances, like alcohol. Specifically:
- Be cautious of using CBD if you are taking medications that thin the blood (eg, heparin, warfarin, ibuprofen) as CBD can ramp up the blood-thinning effect.
- CBD can increase the depressant effects of alcohol when taken in conjunction so it may not be wise to take them together.
Remember that CBD use for pain and related symptoms is not an exact science, so you may need to try more than one brand and method before feeling relief. The good news is that, to date, CBD is not considered to be physically addictive, and there’s no history of anyone overdosing on it, so a little trial and error likely won’t hurt as long as you are sourcing safely.
HAVING THOSE HARD CONVERSATIONS ABOUT CBD USE
CBD is not marijuana – even though it can be derived from the marijuana plant. Still, some CBD products contain THC, and for some people these products may work better (remember the entourage effect). The stigma surrounding marijuana-derived treatments can be difficult for people who benefit from their medicinal effects. Having honest conversations with family members (including how to talk to your kids about CBD and medical marijuana use) about the science and history of medicinal cannabis use is often a good place to start.
WHAT CAN I DO RIGHT NOW?
- Find out what your state has legalized. The CBD Awareness Project lists state-by-state laws and initiatives while the National Organization for the Reform of Marijuana Laws (NORML) lists regulations. You can also try Leafly’s search engine
- Think about the type of CBD you may wish to try – a topical, an oil, edibles, etc. Start small and go slow.
- Look into a local dispensary and schedule an appointment with your doctor to talk about which CBD product may work for your specific symptoms.