Cannabidiol


Cannabidiol is a phytocannabinoid, one of 113 identified cannabinoids in Cannabis, along with tetrahydrocannabinol, and accounts for up to 40% of the plant's extract. Medically, it is an anticonvulsant used to treat two rare forms of childhood epilepsy. It was discovered in 1940. Clinical research on CBD has included studies related to the treatment of anxiety, addiction, psychosis, movement disorders, and pain, but there is insufficient high-quality evidence that CBD is effective for these conditions. CBD is sold as an herbal dietary supplement and promoted with unproven claims of particular therapeutic effects.
Cannabidiol can be taken internally in multiple ways, including by inhaling cannabis smoke or vapor, swallowing it by mouth, and through use of an aerosol spray inside the cheek. It may be supplied as CBD oil containing only CBD as the active ingredient, CBD-dominant hemp extract oil, capsules, dried cannabis, or prescription liquid solution. CBD does not have the same psychoactivity as THC, and can modulate the psychoactive effects of THC on the body if both are present. Conversion of CBD to THC can occur when CBD is heated to temperatures between 250–300 °C, potentially leading to its partial transformation into THC.
In the United States, the cannabidiol drug Epidiolex was approved by the Food and Drug Administration in 2018, for the treatment of two seizure disorders. While the 2018 United States farm bill removed hemp and hemp extracts from the Controlled Substances Act, the marketing and sale of CBD formulations for medical use or as an ingredient in dietary supplements or manufactured foods remains illegal under FDA regulation, as of 2024.

Medical uses

Epilepsy

In the United States, the Food and Drug Administration has indicated only one brand of prescription cannabidiol, sold under the brand name Epidiolex, for the treatment of seizures associated with Dravet syndrome, Lennox–Gastaut syndrome, or tuberous sclerosis complex in people one year of age and older. While Epidiolex treatment is generally well tolerated, it is associated with minor adverse effects, such as gastrointestinal upset, decreased appetite, lethargy, sleepiness, and poor sleep quality.
In the European Union, Epidyolex is indicated for use as adjunctive therapy of seizures associated with Lennox–Gastaut syndrome or Dravet syndrome, in conjunction with clobazam, for people aged two years of age and older. In 2020, the label for Epidiolex in the US was expanded to include seizures associated with tuberous sclerosis complex. Epidiolex/Epidyolex is the first prescription formulation of plant-derived cannabidiol approved by regulatory bodies in the US and Europe.

Antimicrobial property

CBD demonstrates potent antimicrobial properties primarily against Gram-positive bacteria, including several ESKAPE pathogens, by disrupting their cell membrane. While generally ineffective against Gram-negative bacteria due to their protective outer membrane, CBD has shown some activity against specific Gram-negative pathogens like Legionella pneumophila, Moraxella catarrhalis, and Neisseria species. The efficacy of CBD has been demonstrated in topical applications using ex vivo pig skin and mouse models, highlighting its potential as a therapeutic agent.

Other uses

Health benefits for CBD beyond its approved medical uses are unproven; there are potential risks like liver damage and drug interactions.
CBD may help with pain, sleep, and addiction, potentially serving as a non-intoxicating alternative to opioids, but clinical evidence is limited and legal regulations are complex.
There is very limited evidence on CBD use in mental disorders, and current studies do not show clear benefits for treating any mental health conditions.
CBD is strongly advised against during pregnancy or breastfeeding due to unknown effects on fetal and infant development.

Non-intoxicating effects

Cannabidiol does not appear to have any intoxicating effects such as those caused by ∆-THC in cannabis, but it is under preliminary research for its possible anxiolytic and antipsychotic effects. As the legal landscape and understanding about the differences in medical cannabinoids unfolds, experts are working to distinguish "medical cannabis" from "medical CBD therapies", which would commonly present as having a reduced or non-psychoactive side-effect profile.
Various strains of "medical cannabis" are found to have a significant variation in the ratios of CBD-to-THC and are known to contain other non-psychotropic cannabinoids. Any psychoactive cannabis, regardless of its CBD content, is derived from the flower of the genus Cannabis. As defined by US federal law, non-psychoactive hemp, regardless of its CBD content, is any part of the cannabis plant, whether growing or not, containing a ∆-tetrahydrocannabinol concentration of no more than 0.3% on a dry-weight basis. In the United States, certain standards are required for legal growing, cultivating, and producing the hemp plant, but there are no federal standards for quality being enforced in the hemp industry. Certain state regulations are in place, but vary state to state. For instance, the Colorado Industrial Hemp Program registers growers of industrial hemp and samples crops to verify that the dry-weight THC concentration does not exceed 0.3%.

Available forms

, an oromucosal spray made of a complex botanical mixture containing cannabidiol, delta-9-tetrahydrocannabinol, and additional cannabinoid and non-cannabinoid constituents from cannabis sativa plants, was approved by Health Canada in 2005, to treat central neuropathic pain in multiple sclerosis, and in 2007, for cancer-related pain. In New Zealand, Sativex is "approved for use as an add-on treatment for symptom improvement in people with moderate to severe spasticity due to multiple sclerosis who have not responded adequately to other anti-spasticity medication."
Epidiolex is an orally administered cannabidiol solution. It was approved in 2018 for treatment of two rare forms of childhood epilepsy, Lennox–Gastaut syndrome and Dravet syndrome, and seizures associated with tuberous sclerosis complex. In the US, it is approved in these indications for people one year of age and older.

Side effects

Research indicates that cannabidiol may reduce adverse effects of THC, particularly those causing intoxication and sedation, but only at high doses. Safety studies of cannabidiol showed it is well tolerated, but may cause fatigue, somnolence, sedation, diarrhea, or changes in appetite as common adverse effects, with the most common being somnolence and sedation. Side effects of CBD are dose related. Epidiolex documentation lists sleepiness, insomnia and poor quality sleep, decreased appetite, diarrhea, and fatigue.
In November 2019, the US Food and Drug Administration issued concerns about the safety of cannabidiol, stating that CBD use has potential to cause hepatotoxicity, interfere with the mechanisms of prescription drugs, produce gastrointestinal disorders, or affect alertness and mood. Over 2020–23, the FDA updated its safety concerns about CBD, acknowledging the unknown effects of protracted use, how it affects the developing brain, fetus, or infants during breastfeeding, whether it interacts with dietary supplements or prescription drugs, whether male fertility is affected, and its possible side effects, such as drowsiness.
, 1,085 people contacted US poison control centers about CBD-induced illnesses, doubling the number of cases over the 2018 rate and increasing by nine times the case numbers of 2017. Of cases reported in 2019, more than 33% received medical attention and 46 people were admitted to a hospital intensive care unit, possibly due to exposure to other products, or drug interactions with CBD.
In 2022, the FDA stated that "scientific studies show possible harm to the male reproductive system, including testicular atrophy, harm to the liver, and interactions with certain medications. The FDA has not found adequate information showing how much CBD can be consumed, and for how long, before causing harm. This is particularly true for vulnerable populations like children and those who are pregnant."

Interactions

Laboratory evidence indicated that cannabidiol may reduce THC clearance, increasing plasma concentrations which may raise THC availability to receptors and enhance its effect in a dose-dependent manner. In vitro, cannabidiol inhibited the activity of voltage-dependent sodium and potassium channels, which may affect neural activity. A recent study using X-ray crystallography showed that CBD binds inside the sodium channel pore at a novel site at the interface of the fenestrations and the central hydrophobic cavity of the channel. Binding at this site blocks the transmembrane-spanning sodium ion translocation pathway, providing a molecular mechanism for channel inhibition, which could contribute to a reduced excitability. A small clinical trial reported that CBD partially inhibited the CYP2C-catalyzed hydroxylation of THC to 11-OH-THC. Little is known about potential drug interactions, but CBD mediates a decrease in clobazam metabolism. Work with human liver microsomes shows that cannabidiol inhibits CYP3A5 and CYP3A4 to some degree.

Pharmacology

Pharmacodynamics

In vitro, cannabidiol has low affinity for, and acts as a negative allosteric modulator of the CB cannabinoid receptor
Cannabidiol may be an antagonist of GPR55, a G protein-coupled receptor and putative non-homologous CB3 cannabinoid receptor shown by in vitro studies to be widely distributed in the brain. Cannabidiol may interact with various neurotransmitters, such as serotonin, dopamine, and GABA.
As of 2024, the cellular effects and mechanisms of cannabidiol in vivo are unknown, as research to date has been inconclusive and based on laboratory studies. The anticonvulsant effects provided by cannabidiol in people with certain forms of epilepsy do not appear to involve cannabinoid receptors. A possible mechanism for the effects of cannabidiol on seizures is by affecting the neuronal movement of calcium in brain structures involved in the excessive electrical activity of seizures.