Interview: NYU Doctor Explains The Best Way To Consume CBD
n February, the Department of Health announced that it had begun ordering all restaurants and bars in the city to stop selling CBD-infused products, citing an FDA ruling from December saying that it is “unlawful to add CBD to food or drink.” The embargo was postponed until this summer, and City Council member (and Health Committee chair) Mark Levine tells Gothamist he is working on legislation to prevent the ban from going through. But it is unclear whether it will be ready by the June 30th deadline, and local businesse owners are still wondering whether their CBD products fall under the new rules, and how they can adapt to the changing CBD landscape.
It’s not like things are much clearer for CBD users as well. CBD, a.k.a. cannabidiol, is one of more than 80 naturally occurring active compounds found in cannabis plants. But it lacks the psychoactive tetrahydrocannabinol, a.k.a. THC, the compound which gives weed its extra oomph. Since it doesn’t get you high, the applications for CBD are seemingly limitless.
Two years ago you probably wouldn’t have found many people who had even heard of CBD; now, it’s an ubiquitous product available in corner bodegas. Even now, you’d still be hard-pressed to find anyone who could explain what CBD does exactly.
People claim it can help with a wide variety of maladies, from insomnia and anxiety to Crohn’s disease and fibromyalgia. It’s become the ultimate nexus point between the wellness industry, the burgeoning legal marijuana industry, and the alternative medicine community. It’s also made it the subject of great hype and considerable skepticism, especially because there has been very little research done on it, and even less oversight of any kind—one recent study that evaluated dozens of CBD products ordered online found that nearly 70 percent were not labeled accurately.
In the hopes of trying to separate fact from fiction, we spoke to Dr. Orrin Devinsky, the director of NYU Langone’s Comprehensive Epilepsy Center who has been closely studying CBD since 2013. He spearheaded the studies that led to the FDA approving the first drug containing CBD, Epidiolex, which is used to reduce seizures associated with severe forms of epilepsy.
What are some of the scientific findings that you have gathered about the usage and benefits of CBD? CBD is a unique molecule. It works on a variety of receptors in the brain, some of which are relatively unique to CBD, and certainly the combination of working on more than six different receptors in the way it does is quite unique to CBD. We have proven [its effect], and it has led to FDA approval of CBD to treat several rare epilepsy syndromes in that form of CBD. Epidiolex is now on the market and available to patients who have those disorders.
But there is a lot of additional data from animal studies and small human studies to suggest that CBD may have benefits for a variety of other disorders, from anxiety to autism to sleep induction for people who have insomnia, to sleep disorders and inflammatory disorders, so it has a very wide range of potential uses. However, outside of the small range of epilepsy disorders I described, everything else is largely anecdotal, although albeit sometimes supported by animal data. We’re really at the stage where we need to get a lot more information.
Do you think that people have jumped the gun in terms of claiming it can be used to treat a wide variety of maladies? It’s exploded in popularity over the last year. Yes, I think there’s no doubt that as far as the way medicine and science progressed, we try to do it through carefully designed and executed trials where both the physician or investigators, as well as the patients or children of parents who are the study subjects, neither of them know what drug they’re on, because everyone is biased. And with CBD, there is so much hype and religion—and I mean religion in the sense that there is a strong amount of belief without a strong amount—and in some cases without any—data to support it.
And keep in mind CBD is a drug. Yes it’s natural, but we know from our double blind studies that it does in some cases and in some people have very serious side effects that have led people to quickly leave some of the clinical trials that they’ve been in, [like] significant weight loss, diarrhea, elevation of liver enzymes. So it is a drug, it interacts with other drugs, and it is something that, although it is natural, like all drugs it has potential benefits and risks.
“…for anyone who consumes CBD, if it’s taken alone or after a meal that’s high in carbohydrates, you only absorb about four to six percent of the CBD. Whereas if you take it after a high fat meal, you can absorb up to 16 to 20 percent. It’s an enormous difference.”
What do you recommend to people who are curious about CBD, and they see it at their local restaurant or bodega and they want to try buying it and taking it? I think they ideally should become educated about it. They should read about it. They should try to go to websites or other sources that are from reputable organizations. One way is to go to a site like PubMed, which is the National Library of Medicine. And if you type in cannabidiol, you’ll probably get several thousand articles, [especially] if you’re interested in using it to treat anxiety, or autism, or insomnia. You could add that keyword, and at least start to see what the scientific data is.
It’s also important to know what dose you’re taking, as with any medication. So, many individuals, for example an adult with anxiety, might be taking 300 to 600 milligrams per day in the studies that have shown benefit. And yet that’s a dose, if you’re getting it from one of the online reputable sources in Colorado or California that will ship a hemp-derived CBD to people in New York state, that may cost you three or four hundred dollars per month. So many people will use a much lower dose, but those low doses have not been shown to be effective. So I think there’s just this huge disconnect of everyone’s thinking it’s the next panacea that’s going to cure every ailment that they have, and what the data is which is far short of that.
And it’s especially hard because my understanding is that there is no one way to recommend dosage to people—everyone has a different body reaction to the amounts. And the thing that I’ve been told is that you have to do trial and error, which seems very imprecise from a layman’s perspective. Yes, and I think one of the issues you bring up is going to a bodega. Now, if you go to a bodega, even if they have the same supplier giving them “CBD,” you have no idea who’s mixing it, how consistent the batches of what they get of CBD are, how they make their muffins or whatever you’re consuming. And so the dose may vary tremendously, even going to the same place and thinking you’re getting the exact same dose, there could be a two, three, four-fold variation.
What amount is considered inconsequential then? I think it varies by different people like with any drug or medication some people are remarkably sensitive and some people are remarkably insensitive. So typically I think 30 milligrams for an adult would be a very low dose of CBD, although some people may gain some beneficial or side effects from that kind of dose. Many others are taking in the range of 100 to 600 or more milligrams a day.
On top of that, something very few laypeople are aware of at this time, but I think it’s a critical point: for anyone who consumes CBD, if it’s taken alone or after a meal that’s high in carbohydrates, you only absorb about four to six percent of the CBD. Whereas if you take it after a high fat meal, you can absorb up to 16 to 20 percent. It’s an enormous difference. So since it is expensive for the people who are using it as a medicinal agent to treat different disorders, even if it’s a 30 milligram capsule from a reputable supplier, you should take it with a high fat meal or snack. And that could be anything from olive oil to guacamole avocado to a couple bites of a ribeye steak. But something with fat in it is going to greatly enhance the absorption, and the value for your dollar.
That’s fascinating, because there’s been an explosion in people creating CBD-infused foods and sugar, and also putting it into caffeinated beverages and alcohol. And I’ve had a lot of questions about whether that is actually augmenting the use of it, or if it’s dulling the effects of it. So it’s complicated. I think putting it with those things, most of those things like caffeine or alcohol have just not been studied, and I think when things haven’t been studied, scientists and physicians tend to be humble and say, “I don’t know what happens.”
There is an interesting interaction of CBD with THC that has been very well-characterized. THC stimulates a receptor in the brain, which is what leads to the psycho activity of THC, called the CB1 or cannabinoid one receptor. It turns out CBD blocks that receptor—not terribly strongly, but it blocks it. So for people who consume a small amount of THC with a large amount of CBD, you are dramatically if not completely eliminating a lot of the effects of the THC. So it’s something to keep in mind, because many people do consume the two of them together.
Right, and there are versions of CBD being sold in certain states that are combination THC/CBD. Absolutely, including New York state. So I’m a physician in both New York state and New Jersey, who is part of the state medical marijuana program. And that’s exactly right. Most of the drugs you can prescribe, if we want to call them drugs to those medical dispensary programs, are combinations of CBD and THC. And then certainly for people going to dispensaries in other states where it’s legal or recreational, like California and Colorado, largely most of the things that those dispensaries have will be combinations. Although they may have pure THC and pure CBD, most of the preparations they have combined them both.
Let me make sure I’m getting this right, because it seems counterintuitive: the THC/CBD hybrid products actually wipe out the effects of the THC? Let’s just say for example that it’s 20 milligrams of CBD and half of a milligram of THC, so a much higher ratio of CBD than it is THC. There is enough CBD in there to dramatically reduce what would have been the effect of half a milligram of THC taken by itself. So the CBD will actually dampen down the psycho activity of the THC. As best we know the THC doesn’t really affect what CBD does on many of the places it works in the brain, and in some places they actually seem to act similarly on those other receptors. But on the CB1 receptor, the one that gives THC its high producing or psychoactive properties, CBD actually is a mild blocker of that receptor while THC stimulates the receptor.
You had been looking at the effects of CBD on seizure patients. Now that Epidiolex is on the market, what is your research focused on now? I have been involved with some other trials of CBD and CBDV, which is another related cannabinoid in treating individuals with autism. And I also have some interest in looking at anxiety disorders as well.
Have you had any sort of preliminary conclusions or thoughts about the effect of CBD on anxiety? Because I know that’s a reason a lot of people cite for why they’re interested in taking it. I think there is some data to support that CBD can help some people with anxiety. I’ve seen that in my practice as a prescriber in New York and New Jersey. However, it’s anecdotal data, and I think we desperately need to get more rigorous scientific data, which is what many of us are trying to do right now.
Have you ever used CBD for yourself? I have not. No, I fortunately don’t have any ongoing medical disorders for which I need it, so I have not taken it.