Monday 18 February 2019

CBD: Miracle or Menace?

It's the non-psychoactive sister of cannabis with a host of celebrity fans that's being incorporated into everything from face creams to beers. As the demand for CBD products rises, Regina Lavelle explores whether it's worth the hype or simply another snake oil, and if using it could put you in danger

Demand for CBD products is on the rise
Demand for CBD products is on the rise
The next big thing: Gwyneth Paltrow spook of her interest in CBD Goop health conference in LA last summer
CBD Marshmallows from UK company The Marshmallowist
CBD products from Irish company Celtic Wind Crops
Positive results: Bekkii Spain from Co Sligo uses CBD to help control her panic attacks. Photo: Colin Gillen/framelight.ie

When it comes to spotting outlier subjects and sucking them into the mainstream orbit, there is no greater gravitational force than Gwyneth Paltrow. Her most recent cause is cannabidiol or CBD, as it's known - one of the brightest new stars in the 'wellness' galaxy.

At last June's Goop Health conference in LA, Paltrow moderated a panel on cannabis- and CBD-derived products. "I love this subject," said Paltrow. "It really has the potential to shift old patterns of thought and change lives, and I feel like we really could be on the precipice of something a lot bigger than we realise, scientifically."

Mandy Moore told reporters at the Golden Globes that she was using CBD oil to help relieve high heel pain. Just a couple of weeks ago Phillip Schofield and Holly Willoughby were trying out the CBD-laced marshmallows and gummies on the This Morning couch. CBD is now decidedly mainstream.

So, what is CBD? Is it a drug? What does it do and how did it become so popular?

CBD is a constituent of cannabis, but doesn't contain its psychoactive ingredient, THC, Tetrahydrocannabinol, or if it does, only in trace amounts. (CBD products in Ireland are only legally permitted to contain 0.2pc of THC. CBD is not cannabis, which is illegal.)

Whereas once hemp products tended to induce an awkward silence in polite society, CBD has undergone a very middle-class makeover, infusing everything from collagen serums costing €80, to marshmallows retailing at £15 (€17) for a pack of six in the UK. Then there's CBD-enhanced craft beer, Cloud9, a 4.3pc IPA retailing around £5 (€6) and myriad gels, balms, ointments and shampoos. There are many claims about what CBD does or can do. But the main reasons people seem to use CBD, in either topical or tincture form, is for pain relief, to ease anxiety or the symptoms of panic and to aid sleep. In addition there are other claims, often used with beauty products, that CBD has anti-inflammatory and anti-acne properties.

Last month, two former Goop directors, Ashley Lewis and Meredith Schroeder, launched Fleur Marché, an e-commerce site they refer to as "a cannabis apothecary" and has already been referred to as the "Sephora of CBD".

"Despite the fact that cannabis (and CBD specifically) is taking centre stage in the health and wellness industries, the retail space is fragmented, the experiences are clunky and unsophisticated, there is not great education on what the various products do, where they were sourced - are they safe, clean, tested, and how to use them," they told business magazine Fast Company.

Fleur Marché is a slick-looking website. You can shop 'by need', according to a list including Anxiety, Sleep, Pain Relief, PMS, Beauty and Skincare and Pets (how very Goop). The products are beautifully packaged and there are infographics explaining the product terminology. This is designer wellness and CBD is now not merely acceptable, it is aspirational.

Proving that you can never have too much of an on-trend thing, last week vogue.com announced the launch of Standard Dose, a website intended as a curated one-stop-shop for the "best CBD products on the market". Vogue reports that founder Anthony Saniger "requests every brand provide a product's lab tests, to ensure the actual CBD contents match those indicated on the packaging, before submitting everything to a third-party lab for a second round of independent testing."

Ireland already has its own CBD success story in the form of Celtic Wind Crops, founded by Joe Gavin and Paul McCourt. The company, which grows its product in the Cooley Peninsula in Louth, harvests every September before producing CBD oil, capsules and powders. The company describes its process as "seed to shelf", riffing, one presumes, on the "farm to fork" line which denotes full traceability of product.

"Our products are fully legal and compliant with EU regulations. We grow our own hemp and have control over the entire process from planting the seed, to producing and selling the product. All of this gives our customers great peace of mind and they trust our product. This is very important to us as a brand," says Joe Gavin, the company's CEO. Celtic Wind Crops products sell on its website, as well as in pharmacies and health stores, for between €29.95 and €79.95.

Unsurprisingly, given the outbreak of commercial enthusiasm, the European market for CBD products is expecting to reach €2bn by 2020, with the US market expected to reach a value of €3bn.

Further driving interest there is a passionate online community dedicated to sharing information on CBD, from the best brands, to the most efficient methods of ingestion, to new studies claiming efficacy. However, these communities are not official sources of information. Since supplement manufacturers are forbidden from making medical claims, this means it can be difficult for the layperson to establish what exactly it is CBD does or can do.

How, for instance, can one ingest - indeed some retailers recommend quite liberal ingestion of CBD oil per day - a component of cannabis without feeling comparable effects? To answer this it's important to differentiate between CBD and THC.

"THC and CBD are completely different molecules, both found within the cannabis plant," says Dr David Finn, Professor of Pharmacology and Therapeutics at NUI Galway, Co-Founder and Co-Director of the Centre for Pain Research and a Science Foundation Ireland-funded investigator within the Centre for Research in Medical Devices (CÚRAM). He is also a researcher in the area of CBD.

"They're both phytocannabinoids - plant-derived cannabinoids, but they have a different chemical structure and a different pharmacology. So they work in the body in a different way. CBD doesn't have the same psychoactive profile as THC so it doesn't produce euphoric effects like THC. However, you will often read that cannabidiol doesn't have any psychoactivity, but that isn't quite correct.

"It does have actions in the brain. It can affect mood. It can have anxiolytic, meaning anti-anxiety, effects, and anti-epileptic effects. So it's still a substance which can have effects on the brain."

And it is these psychoactive effects that some believe offer tangible benefits. Far from the glamour and narcissism of Hollywood wellness fads, people suffering real illnesses are turning to CBDs for new hope.

Bekkii Spain is a 28-year-old mother-of-one from Co Sligo. When she was 24, Bekkii suffered a series of severe panic attacks. "I believed my throat was closing over," Bekkii says, "as it got worse my throat would go dry, I would find it difficult to breathe. Before I got to see anybody or have any counselling I was admitted to a psychiatric hospital where I spent a few months.

"I became agoraphobic, I felt unsure of going anywhere. I kept [her prescribed] pills with me, in case of another panic attack. But they would make me dizzy or drowsy, the day after I took them I would almost feel hungover."

Bekkii started researching her condition online with a view to finding out more about treatment options. A blogger she followed was writing about CBD in relation to panic attacks.

"I'm naturally very wary of anything that is recommended, so I read around the brands and the options," Bekki says. "I took it in sublingual form (drops placed under the tongue). The recommended dosage was a full dropper but I only used half. I would take it if I felt the physical symptoms of a panic attack coming on. That was September 2017.

"For me, it's had a big impact. Before I couldn't really go to places, I couldn't really leave the house. Now, I've started to venture out. I keep the CBD oil with me, but I feel like I can control the panic attacks.

"I wouldn't say it's been the only driver of my recovery - I pushed myself to challenge my anxiety. CBD on its own will only do so much. But it's worked for me in a way other drugs didn't. It gave me an ease from my nerves and it's more fast-acting than other drugs."

Spain is probably unusual in her determination to ensure the efficacy and seek assurances on the safety of an over-the-counter product. And it seems likely that many of the CBD range of products will not have their claims quite as assiduously tested by their consumers.

It is also important to underline that there are three families of CBD product, governed by different regulations.

The first are foods and food supplements. According to the legislation, food supplements include "capsules, pastilles, tablets, pills and other similar forms, sachets of powder, ampoules of liquids, drop dispensing bottles and other similar forms of liquids and powders."

Supplements are regulated by the Food Safety Authority of Ireland, FSAI, and new products for the Irish market must be notified to the Authority. Some products which have been sold in the EU prior to 1997 fall into a sub-category which means they are also legal to sell.

Then there are cosmetics and health-related products which are not medicines. These are regulated by the HPRA, under the Cosmetics Regulation and are defined as "any substance of mixture intended to be placed in contact with external parts of the human body." Again, these products cannot make or imply any medicinal claims.

And finally there are the medicines, only one of which - Sativex, which contains both CBD and THC and is indicated for treatment of spasticity in Multiple Sclerosis - is licensed for use in Ireland. Medicinal drugs go through rigorous testing and clinical trials before being approved by the European Medicines Agency (EMA), in conjunction with our own Health Products Regulatory Authority (HPRA).

That said, it is important to make the distinction between CBD supplements and medicines. Supplements are not subject to the same rigorous regulation, and they should not be used interchangeably with medication, unless under the specific instruction of a medical professional. This should be especially the case for those taking antidepressants or any medication for mental issues.

And it is here there is particular cause for concern: that individuals may depart from the advice of their doctor, and instead heed the counsel of online advocates. A spokesperson for the FSAI says: "There is no minimum level of CBD that must be in a food or food supplement. However, the declaration on a label must be accurate." Currently, the Authority says, "more than 100 [products] have been notified."

This week, Gogglebox stars Steph and Dom Parker drew attention to the debate about the use of medicinal CBD as a treatment for epilepsy. In a moving Channel 4 documentary about their 18-year-old son, Max - who has been suffering up to 130 seizures a day since infancy - they asked whether the CBD treatment currently denied to him in the UK might change his life.

There is a CBD-based medicine - Epidiolex - which has already been licensed by the US FDA (Food and Drug Administration) for treating certain types of epilepsy, which is expected to be licensed by the EMA in the coming months. "Epidiolex has gone through clinical trials for Dravet Syndrome and Lennox-Gastaut Syndrome, both rare forms of childhood epilepsy which are currently very difficult to treat and there is now good data on its efficacy," says Peter Murphy, CEO of Epilepsy Ireland. "That puts it at a very different level to the CBD you might buy as a supplement. And it's very much a welcome addition to the treatments that are available for children with these devastating forms of epilepsy.

"But it is important to draw a distinction between medications that have undergone rigorous testing and other unstandardised products that are not licensed for medicinal use. I don't think one should take a different approach to assessing the safety and efficacy of CBD than you would with any other drug - even if it's 'natural'," he continues.

"There's a lot of misunderstandings, starting with medicinal cannabis in general, that it would be a magic bullet if only it was available. The evidence so far suggests that it may reduce seizures in some people with certain types of epilepsy, but there isn't evidence at the moment to support its widespread use as a first-line epilepsy treatment. Yes, it can be effective, but for certain people and in limited cases. The bottom line is that we need to develop a better understanding about all aspects of medicinal cannabis through robust scientific research.

"We also need to be realistic about all new medications when they come out. There's been a flurry of interest around CBD, but a lot of this is probably related to these products being cannabis-based rather than the potential benefits we can expect, even from licensed products, which appears to be similar to other epilepsy drugs."

There is no doubt that for some conditions, cannabidiol has proven efficacy. "When we talk about the drug CBD there have been some clinical trials and some animal studies. There is a reasonable body of evidence for some indications - chronic pain, anxiety, epilepsy," adds Professor Finn of NUI Galway.

But when it comes to non-medical products he is more cautious. "The evidence for most of these products is very, very scant. The majority have not been tested in clinical trials. In some products that are available in health food stores and online, we don't know with any certainty what concentration of CBD they contain. They may contain only trace amounts which don't achieve pharmacological efficacy. They may also have some impurities or lack consistency from batch to batch," he says.

Despite her enthusiasm for the product, Bekkii Spain is also cautious about advocating CBD to other anxiety sufferers. She believes that since the industry is enjoying such a boon, that there are plenty of unscrupulous sellers more than happy to capitalise on what is - if we're honest - quite a vulnerable and optimistic market.

Spain advises caution and says she has sought assurances in terms of the ingredients and the processing, but she says that one product she tried "just didn't work. It went straight in the bin. After that I learned to speak to the supplier."

CBD has proven efficacy. It does work - in some areas. But more research is needed, if even only to allay sceptics and to make the market less hospitable to rogue resellers whose product may have escaped authorisation.

What is certain is that this is a product which can work. The lesson here is very much do your research and if you have any medical issues, take advice. And, as always, caveat emptor.

International Epilepsy Day is February 11 and Epilepsy Ireland is hosting an open evening in Dublin, including a talk on medical cannabis. See epilepsy.ie

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