In a nod to the reality that people with arthritis are turning to cannabidiol (CBD) to quell pain and manage other symptoms, the Arthritis Foundation has released guidance to help them better understand this trendy compound and the risks associated with it.
Little research has been done on CBD in humans — and none on people with arthritis, the foundation asserts. Still, they wanted to look closely at this supplement because of its increasing popularity.
“Patients are not waiting for more research. They are using CBD now,” says Marcy O’Koon, the senior director of consumer health at the Arthritis Foundation, in Atlanta. “We realized it was upon us to develop something to help people to be safe, to not fall prey to aggressive marketing and inaccurate claims,” she says.
What Is CBD, and Why Has Its Popularity Soared?
CBD is one of the many chemicals known as cannabinoids that occur naturally in the cannabis plant, which includes both hemp and marijuana. Most of the CBD available in stores and online is made from hemp, a plant that does not contain much tetrahydrocannabinol, or THC, the chemical in marijuana that’s responsible for making people high.
Consumers’ usage of CBD has exploded in recent years. Whereas few people had even heard of CBD a few years ago, now it is poised to become a $22 billion business by 2022, according to the Brightfield Group, an industry analyst. One reason for the growth: The latest Farm Bill finally made hemp legal in the United States, removing it from the prohibited Schedule 1 category of drugs that includes marijuana and ecstasy. And, of course, in states where medical or recreational marijuana are now legal, CBD (with or without THC) can be purchased in dispensaries.
CBD Is Already Widely Used by People With Arthritis
Even without studies showing that it works for arthritis, people with the condition are diving into the marketplace. A survey by California researchers of nearly 2,500 respondents, published in Cannabis and Cannabinoid Research in July 2018, found that chronic pain and joint pain are the top two medical conditions for which people take CBD. The next three — anxiety, depression, and insomnia — also affect many people with arthritis.
The Arthritis Foundation conducted its own online survey this past July, of 2,600 people with arthritis. Because these people elected to be in the survey, the results are not necessarily representative of everyone with arthritis. Still, the survey found that 79 percent of respondents had tried CBD or were considering using it, primarily to relieve pain, the most burdensome arthritis symptom.
Nearly 30 percent of respondents said they were currently using CBD, and three out of four of them reported getting relief. Not only had their physical function and morning stiffness improved, many said it helped them sleep or be less fatigued, or reduced symptoms of anxiety or depression.
Research on CBD Severely Limited
The Arthritis Foundation is clear that its guidelines are not meant as an endorsement of CBD. “The guidance was worded very carefully. We are not trying to suggest that it is effective or absolutely safe. We are projecting the state of knowledge as it is,” O’Koon says.
Unfortunately, that state of knowledge is sparse. As the guidelines note, “Animal studies have suggested that CBD has pain-relieving and anti-inflammatory properties, but these effects have not been validated in quality studies in humans.”
Using CBD Safely When You Have Arthritis
Still, the Arthritis Foundation wants to help consumers navigate this often-fraught marketplace as best as they can. Important advice from their guidelines includes:
Go low and slow. Without adequate research, there are no established clinical guidelines for how much CBD to take. Start with a low dose of just a few milligrams, adding a few more after a week. If that doesn’t help, go up in small increments in the next several weeks. If that brings relief, continue taking that dose twice daily to maintain a stable level of CBD in the blood.
You can currently find CBD in lotions, suppositories, food, edibles, vaping, and other means. The Arthritis Foundation recommends avoiding all these delivery systems. Instead, they suggest swallowing CBD in capsules, or using a spray or tincture under the tongue (known as sublingual delivery) and holding it there for a minute or two.
Don’t shun DMARDs. “CBD should never be used to replace disease-modifying drugs that help prevent permanent joint damage in inflammatory types of arthritis,” the guidelines state. CBD might help with the symptoms of arthritis, but there is no evidence it can alter the course of your disease, O’Koon emphasizes.
And even though your doctor may not know much about this substance, it’s important to keep your medical care provider informed. “CBD use should be discussed with your doctor in advance, with follow-up evaluations every three months or so, as would be done for any new treatment,” the guidelines state.
Beware of drug interactions. One important reason to discuss CBD with your doctor is that scientists have identified many classes of drugs that theoretically might interact with CBD, impacting the drug’s effectiveness.
For people with arthritis, medications that might raise concern are corticosteroids (such as prednisone), tofacitinib (Xeljanz), naproxen (Aleve), celecoxib (Celebrex), tramadol (Ultram), certain antidepressants, including amitriptyline (Elavil), citalopram (Celexa), fluoxetine (Prozac), mirtazapine (Remeron), paroxetine (Paxil), sertraline (Zoloft), and certain medications that are sometimes prescribed for fibromyalgia, including gabapentin (Neurontin), and pregabalin (Lyrica).
This doesn’t mean you must avoid CBD if you are on these medicines, O’Koon says, but it’s important for you and your doctor to pay closer attention to symptoms and side effects.
Shop very carefully. CBD is currently sold in all kinds of shops — not just dispensaries but also hair salons, restaurants, health-food stores, spas, and more. Because CBD products are largely unregulated in the United States, the range of quality of these products varies tremendously.
In some cases, CBD products are even mislabeled or, worse, adulterated. A study published in the Journal of the American Medical Association (JAMA) in 2017 found that of the 84 CBD products the researchers bought online, a whopping 43 percent had more CBD than indicated, while 26 percent had less. Eighteen of the products contained unexpected THC.
“There’s a 75 percent chance of getting a product where the CBD is mislabeled,” says Jahan Marcu, PhD, one of the study’s coauthors and a cofounder of the International Research Center on Cannabis and Mental Health in New York City. Dr. Marcu also worries about possible contaminants in CBD products made from hemp, because the plant readily absorbs pesticides, heavy metals, and other harmful substances.
The Arthritis Foundation urges consumers to buy from companies that take steps indicating they care about quality. These include following good manufacturing practices established by the FDA for pharmaceuticals or dietary supplements; testing each batch it manufactures and providing a certificate of analysis for each test from a reputable independent lab; and manufacturing its products in the United States, with ingredients grown domestically.
Know when it’s not for you. Good-quality CBD can be expensive, especially if you take it regularly. That’s why the Arthritis Foundation says that to avoid wasting money, “be completely sure that the product is truly having a positive effect on symptoms.”
O’Koon suggests keeping a diary of whether and how your symptoms change. After six to eight weeks, you should notice some differences.
If you don’t, and if you live in a state where medical or recreational marijuana is legal, you might try a marijuana-based product that adds very-low-dose THC to the CBD, the Arthritis Foundation guidelines suggest. This is because some think THC and CBD might enhance one another, boosting their effectiveness.
But if after a few months of trial you’re still not feeling relief, it’s time to throw in the towel. “If you’re not experiencing any benefit, there’s no reason to keep taking it,” O’Koon says.