CBD, Good for Your Gut or Marketing Hype?

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CBD, Good for Your Gut or Marketing Hype?

Leading CBD researcher Dr. Alex Capano weighs in.

The CBD industry is booming. But which claims about its benefits are grounded in solid evidence? In this episode, my guest Dr. Alex Capano—who received the first doctorate ever in cannabinoid science—is our guide to CBD for health. She’ll walk us through important definitions, the differences between isolate, full-spectrum and broad-spectrum, whether CBD is effective for healing your gut, and more.

Episode Intro

Dr. Michael Ruscio, DC: Hi everyone, welcome to Dr. Ruscio Radio. This is Dr. Ruscio and today, I am here with Dr. Alex Capano, and I was really impressed with the recent webinar presentation she was giving about CBD. She’s fairly well-credentialed in this area, and I wanted to have her on to help us navigate this landscape where, boy, it seems everywhere you look now, there’s a CBD product. They’re putting it in fish oil, they’re putting it in skin topical agents, they’re putting it in ChapStick. So this is an exciting area.

[Continue reading below]

Dr. R’s Fast Facts Summary


  • CBD Isolate – May derive some benefit but not as much as Broad Spectrum or Full Spectrum
  • Broad spectrum is better (0 THC present)
  • Full Spectrum is best (may contain some THC)
    • Note: One could fail a drug test because of it
  • Bottom line, CBD works better when surrounded by its other compounds like THC + other certain terpenes but some may prefer to have NO THC present

Summary of CBD for gut health

  • Moderately effective
  • Will likely need some THC for best GI results

Review on cannabis and autoimmunity

  • Study: Cannabinoids and Autoimmune Diseases: A systematic review
  • Review of study can be found here in the Future of Functional Medicine Review
  • Crohn’s RCT, positive results
    • “In a prospective placebo-controlled study with 21 Crohn’s Disease patients [200], cannabis induced clinical remission in 50% of patients. 80% of the participants had nonresponse or intolerance to anti–TNF-alfa.” (Note: anti-TNF-alfa is drug therapy.) “Although, the improvement was only symptomatic, with no induction of remission comparing to placebo. When patients discontinued the cannabis therapy, relapses were noticed in 2 weeks.”
  • Pain RCT, positive results
    • “A randomized double-blind placebo-controlled trial published in 2014, [207] compared medium dose (3.53% THC) to low dose (1.29% THC) cannabis, to see if the analgesia was sufficient in the low doses. The purpose was that if it is as effective as the medium dose, it should be used preferentially, to avoid side effects. Both provided statistically significant 30% reductions in pain intensity when compared to placebo.”

Examine.com review on CBD

What is CBD best for?

  • Pain, sleep and anxiety/mood


  • Daily dosing, roughly 20mg/day (10-30 general range)
  • Evaluate after 2 weeks
  • CBD compounds over time
  • Use it as a preventative measure vs an immediate solution for a flair


Recommended Brands

In this episode…

Episode Intro … 00:00:40
Defining Marijuana, Cannabis, Hemp, CBD … 00:04:23
Isolates, Full-Spectrum, Broad-Spectrum … 00:07:44
Gut Health & CBD … 00:12:52
THC Plus CBD in Gut Health? … 00:23:20
Greatest Health Potential of CBD … 00:26:25
Dosing & Wait Times … 00:27:43
Research Evidence for CBD … 00:31:43
A CBD Brand Recommendation … 00:36:12
Episode Wrap-up … 00:38:16

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But as we’ve discussed on the show prior, when there is an interest in an area, you have both a supporting of science and a supporting of charlatans. We’re trying to navigate through that and not be misled by all the marketers who are looking for an opportunity to make money on selling products. And get to, “Okay, this can help me in this application, here’s how we can really cut through some of the noise.” That’s why I’m glad Alex is here with us today.

So Alex, I guess I’ve put some pretty big shoes out here for you to fill, but I’m happy you’re here to help steward us through this conversation.

Dr. Alex Capano, DNP, CRNP, FNP-BC: Thanks, I hope I can meet that request.

CBD, Good for Your Gut or Marketing Hype? - 240F295086280uMu2rHXrvOkn32VJoIiwaE0hhftXIBc3DrMR:   Yeah, I have no doubt. Can you tell people about your background? It’s very relevant to this area, and I believe you are one of the first to graduate with a focus in cannabinoid research. I’m paraphrasing, but get us to speed on your background and your training.

DrAC:   Sure. So my original training was actually in neuroscience. Then went back to school, got a couple of degrees to become a family nurse practitioner. I practiced full-time seeing patients in primary care, and actually, in sexual medicine mostly. And then went back and got a doctoral degree that’s focused on cannabinoid science.

I have been recognized as the first person to focus on comprehensive cannabinoid science at the doctoral level, because no one else had the opportunity before me. The center didn’t exist. I was really in the right place at the right time and studied in what’s called the Lambert Center for the Study of Medicinal Cannabis and Hemp. That’s at Thomas Jefferson University in Philadelphia. So there maybe still needs to be credentialing around different programs for cannabis, but I was able to get through a couple of years ago.

DrMR:   Nice, well, congratulations to you on being in the right place at the right time. Certainly, it’s a booming field.

DrAC:   Serendipitous, absolutely.

CBD, Good for Your Gut or Marketing Hype? - 240F81762987ozRgpNiLPtYcnRcK6g8jduqNe1zIL5X0DrMR:   One of the areas I wanted to start our conversation with was regarding the potential utility of either cannabis (meaning, smoking pot for lay parlance here) or marijuana—you don’t have to smoke it, you could use it as an edible or what have you, but it would be your complete cannabis that has THC, CBD, and the whole gamut—versus CBD only, which could be derived from hemp, it could be derived from cannabis.

These are typically legal over-the-counter depending on the source, and they have no psychoactivity, meaning they don’t get you high. I just want to give a brief primer on my understanding, certainly not an expert here, but I’ve done a little bit of poking around. So I want to throw these few ideas out there regarding applications to gut and then get your take. And then we can let the conversation evolve from there.

Defining Cannabis, Marijuana, Hemp, CBD

DrAC:   So if it’s okay, I just want to back up a little bit to make sure we’re all working with the right definitions.

There’s a lot of confusion in the space: what is cannabis, what is marijuana, what is hemp, what is CBD?

DrMR:   Yeah, please, let’s get our definitions straight.

DrAC:   So cannabis is either marijuana or hemp. That is the term for the family of plants, the Cannabis sativa plants. And then, inside of the flowers of those plants are molecules called cannabinoids. So CBD is a cannabinoid and THC is a cannabinoid. There are many others, but those are the two most abundant, most well-known and of the moment for a good reason.

THC is the cannabinoid that causes intoxication or gets you high. And a hemp plant is a cannabis plant with 0.3% THC or less. And a cannabis plant with more than 0.3% THC is considered marijuana, and that’s really just a U.S. law definition.

CBD, Good for Your Gut or Marketing Hype? - 240F228796724WMlHmRFrqtATybCH60Vn48C2GWpEoElBEven a cannabis plant, that at one part of its life cycle could have been considered hemp because of that low amount of THC, could mature and then we call it is “go hot” and could evolve into what’s considered marijuana. And that’s important for anyone looking to consume this and wanting to make sure that they stay in federal, legal regulations. So hemp grown in the U.S. and cannabis oils derived from hemp are federally legal. But at the federal level, no cannabis oils derived from what’s considered a marijuana plant are federally legal.

What’s also interesting is that plants that have higher THC tend to have very low CBD and vice versa. So a hemp plant, because it has such low THC, is a great source of CBD-rich oil.

DrMR:   So it’s not something that the industry is doing to try to get around legal restrictions. There’s actually some reason behind why hemp is so popular now?

DrAC:   Yes. So the 2014 Farm Bill created this pilot program of legality, and the 2018 Farm Bill made this permanently legal. So you can have a hemp-derived CBD oil that is only CBD and we call that isolate. You can have it where it’s called broad-spectrum, which means it has these other phytocompounds, these other cannabinoids and terpenes and flavonoids, but has eliminated all traces of THC. And then you can have what’s called full-spectrum, which has all of those compounds in it, plus 0.3% THC or less. So even with the hemp-derived, over-the-counter federally-legal CBD oil, you can have some THC in there. It’s just not considered high enough to cause euphoria and intoxication.

DrMR:   To get you high.

CBD, Good for Your Gut or Marketing Hype? - 240F2655596976AaMCiEULHle0os2A7b6s1RY3LUt5SV2DrAC:   Yeah.

DrMR:   Because really, if you were to state it—maybe not fully technically accurately, but in the simple take-home message—it would be, if it has enough THC to get you high, it’s not able to be sold legally in a lot of states. If it has a minimal amount of THC, not enough to get you high and is derived from hemp, that’s going to be legal, is that a fair…

DrAC:   Yes, good summary.

Isolates, Full-Spectrum, Broad-Spectrum CBD

DrMR:   While we’re on this topic of isolates versus full-spectrum, for the consumer who’s saying, “This one is claiming to be full-spectrum CBD, this one is claiming to be full-spectrum,” meaning the whole plant and all the parts, “this other one is claiming to be an isolate,” is there any consensus in terms of what’s better to use?

DrAC:   Actually, yes. There’s something called the entourage effect, which I always say sounds like pseudoscience to me—the entourage effect—but it’s pretty well-established in the literature. And what that means is that CBD works better when it is surrounded by its constituents or its other compounds that exist naturally in the plant. So we know that when you add a little bit of THC to CBD, you get a more potent response at a lower dose.

And we know that certain terpenes, at least, also contribute to that effect. Beta-caryophyllene, for example, certainly has been demonstrated in the literature to help CBD’s efficacy. I always use this analogy that isolate CBD still works, but you might not get as much bang for your buck with it. It’s like putting a packet of vitamin C powder into a drink and that’s how you get those nutrients, versus eating an orange, which would be full-spectrum.

CBD, Good for Your Gut or Marketing Hype? - 240F284149958NtOMztP975zQk9URilO3y4BE7RryHk7VDrMR:   Great analogy. Okay, that makes sense. So I think that’s one valuable take-home for the audience. Look for a full-spectrum rather than some kind of isolate. And this is typically fairly prominently marketed when it’s full-spectrum, right? You’re going to see that usually displayed somewhere on the label pretty clearly. I feel like that’s a market differentiator many CBD companies are looking to use to show how their products are better than the others. And so it shouldn’t be too hard to find that, right?

DrAC:   That’s true. And then you’ll also see broad-spectrum, which has the other compounds, but no THC. Even a little bit of THC does pose the risk—it’s unlikely—of some of someone failing a drug test. So that’s the middle of the road, you get the other compounds that contribute to the entourage effect. Although THC is arguably the most important compound for that. But at least you’ll get some of it with a broad-spectrum, without the risk of having any THC in your system.

DrMR:   Oh, so the full-spectrum does run the risk of a small amount of THC?

DrAC:   Yes.

DrMR:   Not enough to get you high probably, but enough to potentially fail a drug test?

DrAC:   Yes. It’s unlikely that you could take enough, but the risk is there. So especially department transportation workers, certain people who are subject to drug screenings and really can’t risk that, should know what they’re getting into if they choose a full-spectrum. That there is that risk.

CBD, Good for Your Gut or Marketing Hype? - 240F97655541XIWgpNQy0RxkXxnkcGxA3MMkcZCSExCb 1DrMR:   Gotcha, okay. That’s actually really helpful for people to know. Imagine the surprise if someone failed the drug test because of the CBD product they bought online, and they thought they all had all their bases covered.

DrAC:   Yeah, it’s happened. So I just think informed consent is important in this industry as well.

DrMR:   I’m making a note here for our audience for our Fast Fact notes. So remember, if you’re working in any profession where you might be drug-tested, use the broad-spectrum. You probably don’t want to use the full-spectrum, because that might contain a small amount of THC. Not enough to get you high, but enough to potentially fail a drug test.

DrAC:   Right.

DrMR:   Super important. See, already, you’ve given us what I think is worth the call here. Just those two tips right there. Obviously it has a lot of applicability and could have some nasty consequences for someone who didn’t realize those finer points.

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Gut Health & CBD

CBD, Good for Your Gut or Marketing Hype? - Cannabinoidsandautoimmunediseases AsystematicreviewOkay, so let’s just go into a few of the points regarding gut health now, because that’s something our audience is very curious about. I’m sure we have a number of people listening here who might be struggling with IBS, IBD or general gut symptoms and might have gas, bloating, reflux, the inability to expand their diet. They may have to eat a very narrow cropping of foods to prevent symptoms.

When I looked at a few review papers, there was a paper on cannabis and autoimmunity. They cite two randomized controlled trials with cannabis here. This is a plant that would get you high. And essentially, they found positive results for Crohn’s. It was about a 50% response rate or higher. So in CBD, Good for Your Gut or Marketing Hype? - Examine comsreviewonCBDmy opinion, this randomized controlled trial using cannabis in Crohn’s was pretty impressive. There’s also another randomized controlled trial —this is not GI—showing that pain, which I believe included also some abdominal pain, showed positive results. So that’s pretty encouraging.

Now, I’ll contrast that with Examine.com’s review on CBD. I found Examine.com to be a great source to get an evidence-based synopsis of what a body of literature shows. They review two randomized controlled trials (using the terms loosely here). One in Crohn’s, only using CBD. CBD, Good for Your Gut or Marketing Hype? - Low DoseCannabidiolIsSafebutNotEffectiveintheTreatmentThey found it was safe, but not effective for Crohn’s. And for ulcerative colitis, they found the CBD was also safe. They didn’t hit the threshold of showing effect, but there seems to be a trend that it might help and I’ll include Examine’s level of evidence table there .

So that gives me a little bit of pause with how quickly I rush to recommend CBD for patients with gut ailments. That’s not a ton of research, so we can’t draw too strong of a conclusion from four studies, but it does throttle my enthusiasm a little bit. How do you interpret these findings, Alex? And is there a greater context that we can examine and help people know CBD, Good for Your Gut or Marketing Hype? - ARandomizedDouble blindPlacebo controlledParallel groupPilotStudywhether this would be considered a great, an okay or a poor intervention for gut health?

DrAC:   I would say at this point, okay. That’s mostly based on looking at the mechanism of action and understanding its potential at a cellular level. And then also, it’s frustrating to use this word that’s often used in this space, but the reality is, anecdotal. For me, anecdotal is still an n of a thousand-plus patients that I observe every day. But that’s not a randomized control trial. And that’s obviously how we like to draw our conclusions when we’re using evidence-based practice. The problem is, there are a lot of barriers to researching cannabis, both CBD and THC, and utilizing them in a way where you can do a double-blind randomized control trial, where you can really control dosing, and where it can be plant-derived and full-spectrum oil.

There are a lot of barriers—in the U.S. especially, but also globally—to this type of research. And there are barriers to funding as well. It’s starting to open up a little bit, especially for CBD research, which is nice. But I say, it’s like ouroboros, where the snake is just eating its own tail.

We say, “Well, there’s no research, but we won’t let you do the research,” and “We won’t let you do the research, because there’s no research,” and then it just keeps going. But you really have to separate THC and CBD, and then also plant-derived versus synthetic cannabinoids. There are synthetic cannabinoids and they do act differently on these receptors.

CBD, Good for Your Gut or Marketing Hype? - 240F260205398P5PIQ97LEzNATDimHpvteeYRmNr0P9EeBut if we back up and just look at why we’re even investigating this, it’s because of endocannabinoid receptors and their abundance in GI tissue. We all have an endocannabinoid system. All of our pets have an endocannabinoid system. And it was discovered in the early 90s in Israel, but is unfortunately not really taught in most clinical schools. There’s a major knowledge gap across practitioners about what the endocannabinoid system is, what it does and how we can harness it for a potential across a variety of conditions and symptoms. It’s made up of two different types of receptors, your CB1 and your CB2 receptors.

CB1 receptors are the most abundant G-coupled protein in your brain. They are also in your central nervous system. CB2 receptors are pretty scarce in the central nervous system, but are abundant in the periphery. Particularly on immune cells and in the GI tract, you have these CB2 receptors. THC binds directly to these receptors and alters their function. CBD actually has a pretty low affinity for both of them and just alters functions within the cell. And both CB1 and CB2 receptors have a variety of functions.

They’re exceedingly complex, poorly understood, and we have a lot of discovering to do. But we know that they regulate homeostasis. So they are going to influence everything from your mood and breath and sleep/wake cycle to inflammation and immune response. I think that that’s the most important topic across, really, every chronic condition, but particularly, for GI issues like Crohn’s disease and IBD.

CBD particularly is a pretty potent immunomodulator and anti-inflammatory agent at the CB2 receptors in the gut. And that’s why so many researchers and practitioners are excited about the therapeutic potential for CBD in these conditions. That being said, you’re right, there are really not great randomized control trials that demonstrate that. It’s really case reports and observations anecdotally right now.

CBD, Good for Your Gut or Marketing Hype? - AdobeStock94616623WEBdoctorstethoscopeDrMR:   Right. It is a tough balance to strike. On the one hand, I believe we can learn a tremendous amount with these n of one experiments. This is what I do in the clinic every day, and this is how I’ve really come to develop the clinical model that I use. And it’s also, of course, by evidence. But it’s perhaps equally guided from the boots-on-the-ground clinician in the office treating patients and getting feedback from them.

On the other hand, placebo effect does influence the way one will report their response to a given treatment, and that’s one of the concerns that I have with anything that’s really rising to popularity. If everyone’s talking about how great it is, you’re going to go well beyond the 45% average placebo effect seen in randomized controlled trials and arguably maybe even up to 75-ish% could be influenced by placebo.

So it’s a challenge or it’s a challenging situation to be in, where I’m trying to get a read, but some patients seems so excited about CBD. I’m wondering, is this like other things patients have come in raving about? They rave for a few months, but then a few months later, the placebo effect wears off and they’re no longer raving about it.

So I just pose it as an open thought and question, I don’t have a great answer for it. I guess that’s what we’re struggling with, as the scientific community is trying to get a better consensus on what place cannabinoids or CBD should have in gut care. And I guess that’s something that you’re actually, obviously, trying to answer on a daily basis.

DrAC:   I always tell people, this is not a magic potion that is just going to cure everything for everyone. It really does help some people to live healthier lives and to be free or reduced of symptoms of chronic diseases. But it’s not this magic bullet, this snake oil. I think we need to get away from that thinking, because it actually increases the skepticism, and reasonably so.

DrMR:   Right, yeah. That’s actually an excellent point. I just want to underscore that really quickly for providers and for patients. If you want to kill the ability of something to permeate its way more into the medical and scientific system, be very excited about it. What that will do is make people skeptical of it. Yeah, I think that’s an excellent point.

CBD, Good for Your Gut or Marketing Hype? - 240F301764642oFM9fF28VEL1XAu5HRZ6p6oqJOlvw4saDrAC:   But we do know that CBD is an anti-inflammatory agent in multiple mechanisms of action. It’s even a COX inhibitor, but it modulates mast cell activity and histamine release from mast cell. It reduces immunoreactive microglia, it decreases PLR responses, promotes adenosine receptor A2A, and the list goes on and on.

So we do know from a basic science perspective what some of these mechanisms are, and then we’re obviously trying to translate that into practice in the real world. Right now, it’s difficult with barriers to research. And also, that some of the research is using doses that are all over the place. Or maybe they say cannabis and they mean THC, or they mean CBD, or they mean both. So we have a long way to go until we have a lot of abundant human data on this.

THC Plus CBD in Gut Health?

DrMR:   Sure. And to the other point you made a few minutes ago, I have had patients come in who’ve sworn by either some type of cannabis containing THC or CBD, so those reports are there. Again, it’s a challenge trying to parse this. And I wonder, do you think—given some of the way the receptors are stimulated by THC vs CBD in the gut—it’s likely we’ll find that having some THC, maybe enough to get you high, getting over that threshold would be better for gut health? Or do you think there’s a probability that we’ll eventually come to learn that CBD alone could be just as effective as a combination of CBD and THC?

DrAC:   I think we’re going to find that you need some THC to get the best effect. I think CBD is a viable option for people who, for a number of reasons, cannot have any THC in their system. We see that CBD works better, but THC has therapeutic value. It has a few more risks that CBD doesn’t have, but at low doses, we see that you can certainly have a therapeutic response without those risks.

And as far as pain goes, THC seems to be a really good antinociceptive, so it reduces that perception of pain. Whereas CBD may be doing the grunt work of actually reducing that inflammation over time, but it’s not necessarily great for acute issues. THC can trick you into thinking you’re not in pain and CBD actually reduces it over time.

DrMR:   That’s a great point. Is there anything else on gut that you feel is worthwhile to explore?

DrAC:   Well, I think the brain-gut connection is so strong. We do see a lot of anxiolytic properties of CBD. Cannabis in general, THC, at certain levels (and it depends on the individual) can reduce anxiety, but at high levels tends to actually increase it. Whereas CBD doesn’t have that risk. It does reduce that anxiety. I think that communication from your brain to your gut of reducing anxiety can promote gut health over time. And you’re the gut expert, but that’s certainly worth considering, I think, for people who are looking to use this.

DrMR:   Agreed, yeah. I mean, especially in IBS cohorts, we know that there’s a higher distribution of anxiety. And I see this clinically with some patients who are very concerned, fearful, nervous about their diet or about their health. That can, in some cases, really limit them from healing, because they’re stuck in this state of worry and fear. So I see the brain-gut connection certainly being a fruitful area or mechanism by which you could help the gut.

Greatest Health Potential of CBD

I guess that’s a good transition into, where do you feel CBD has the most potential for people? And just to clarify, again, for the audience, this would be CBD-only. Where do you feel you get the most bang for your buck?

DrAC:   As far as conditions to treat?

DrMR:   Yes, I’m sorry. For anxiety, sleep, joint pain. Where do you think people should really think about this as a good option?

DrAC:   Pain, sleep, and mood. And mood really being anxiety, and lower down would be depression. Those are the low-hanging fruit that, unfortunately, I think a lot of us are suffering from. They tend to be interrelated: when you’re not sleeping well, you’re more anxious, and maybe you’re in more pain because of all of that.

So pain, sleep and mood are the top reasons people are using this. They’re the reasons that people continue to use it, so they think they are getting symptom relief. And this is certainly a safe option or alternative to some of the other options out there for those conditions. It’s not going to hurt to try, and we do see that most people come back and report success with it. Not everyone all the time, but the odds are in your favor.

Dosing and Wait Times

DrMR:   And you mentioned that THC may act more acutely, and CBD may take a longer time to have an effect. Or at least that’s the inference that I’m drawing, because it has an anti-inflammatory effect. So does that mean that for pain, for sleep, for mood, you should not run the experiment as, “I took some CBD, I didn’t feel anything an hour later, it didn’t work for me,” but instead should consider giving this a certain time period to be able to evaluate if it’s working? Is that a fair way for someone to be dosing this?

DrAC:   Yeah, absolutely. It compounds over time in your body, so you’re going to get more of an effect and greater bioavailability day after day. So I do like the idea of using CBD as a preventative, as opposed to an intervention when you have a flare of something. CBD is something that can hopefully reduce frequency and severities of flares, whether that’s insomnia, anxiety, pain, or a Crohn’s issue. And potentially adding more when those flares still do come.

You’ll have the patient here and there, where they try CBD and five minutes later, their Parkinson’s-related tremors completely stopped, and that’s incredible. But that’s certainly the exception and not the rule. This is something that you should be ideally using every day, and on day 10, you’ll feel more of a difference than you did on day one.

DrMR:   Gotcha.

DrAC:   You should feel something. If you’re using a quality product and you’re using a high enough dose, you should feel something on the first day. You just will probably feel even more on the 10th day.

DrMR:   Do you think there’s a reasonable, give yourself x many days, and if your insomnia or your mood or what have you doesn’t respond, you can depart from the exercise?

DrAC:   Yes, I would say within two weeks, you should definitely feel a difference. Dosing certainly depends on whether you’re using an isolate, full or broad-spectrum. But 60 mg, for example, of a full-spectrum, is a really high dose, in what I observe. If you’re up to 40 or 60 mg a day trying to titrate your dose up and you’re doing that for a couple of weeks and you don’t see a difference, it’s just not working for you.

DrMR:   Would you say the 40 to 60 mg per day range is a good sweet spot target range?

DrAC:   No, that’s actually the higher end.

DrMR:   Okay, so where should people be aiming for?

DrAC:   Most people are going to be around 20 mg a day. I don’t have the exact data on this, but from my experience 10 mg to 30 mg will capture probably 70% of people at a therapeutic range there. Those are levels that really aren’t tested in the literature. Usually they go very, very high, but we see a bell-shaped dose response curve here. That means once you hit your peak, if you take more, you’re actually on the descending end of that bell or curve.

So more is not always better. I tell people start low, go slow. Titrate up. If you don’t feel better adding more or you even feel a little bit worse, you want to go back to that previous dose. But if you’re taking 60 mg a day of a product—that’s actually 60 mg, because there’s no regulation in the space and you may be taking coconut oil but if you’re really taking 60 mg of active CBD and you are not getting a response, you are just somebody who doesn’t respond.

DrMR:   Gotcha. Okay, that’s good to know.

Research Evidence for CBD

And what about the evidence here? I know there’s a booming body of CBD research. I haven’t gone through to see, are we at the point where we have some randomized clinical trials, one for pain, one for sleep, one for mood? Do we have the fortune of maybe having a meta-analysis summarizing clinical trials in one of these areas? Give us a primer on what the evidence looks like here.

DrAC:   Well, the National Academies did a meta-analysis a couple of years ago, and they came to probably over a hundred conclusions. They did conclude that cannabinoids were effective for marked pain relief and that that was supported by high-quality evidence.

The problem is that they didn’t only look at CBD or they didn’t only look at THC, and they didn’t necessarily look at doses or delivery that consistently. There are systematic reviews and meta-analyses out there, but even within those, there’s a lot of variabilities of the studies they look for. So the conclusions tend to be cannabis or cannabinoids, and not necessarily which compounds.

DrMR:   So there’s not a clear distinction between cannabis with THC versus just the CBD. There’s a mixture of both?

DrAC:   Yeah, exactly.

DrMR:   That makes it tough…

DrAC:   And some of these are self-report, which is problematic for a number of reasons. But also, we don’t know what dose people were taking if they’re self-report.

DrMR:   Right. Okay, so you feel that, obviously, there’s some evidence. And there’s a trend in the data, and the trend is strongest for pain, sleep, and mood. Albeit, the data is not perfect, there’s a mixture of CBD and CBD plus THC spattered in there, and some of this suffers from self-reporting. Is that an accurate synopsis?

DrAC:   Yes, absolutely. I just finished a study on hemp-derived CBD oil. It was full-spectrum, but it was over-the-counter, hemp-derived, very low THC, and that effect on opioid use, pain, and quality of life outcomes in chronic pain patients. So we looked at 97 patients over eight weeks, and we followed up with some at a 12-week point. We looked at their opioid use and also pain disability index, their sleep and their mood through validated instruments. And we found that over half of them had titrated down their opioids by eight weeks.

And most of these folks had been on opioids for more than five or 10 years. They’d at least been on a stable dose for one year. That was part of the inclusion criteria, but by adding hemp-derived CBD oil to their regimen, they were able to reduce these opioids, and they had statistically significant improvements in pain, sleep, and mood. So even for some of the people who weren’t able to change their opioids, their pain scores were better. Some of them were out and socializing more and exercising more because their pain was improved. So it felt like it was a win even when they didn’t reduce their opioids. But over 50%. I was pretty happy with that at eight weeks.

DrMR:   And has that been published?

DrAC:   It’s hopefully going to be out in January, and online in about three to five weeks (in print in January). And that dose in that study ranged from 15 mg to 60 mg. But there was only one person at 60 mg. The vast majority were at 30 mg a day.

DrMR:   Great, because the cost difference between 30 and 60 mg a day is quite large, especially depending on the kind of product that they’re using.

DrAC:   Oh, absolutely. And these folks were getting the product for free, for participating in the study.

DrMR:   Lucky them!

DrAC:   Yeah.

A CBD Brand Recommendation

DrMR:   Do you have any brands that you like?

DrAC:   Well, full disclosure, I am the chief science officer for a company called Ecofibre and we do produce our own CBD oils. I did decide to work with them because of their commitment to research, and because I feel like I can remain as objective as I need to as a scientist, without any pressure. They make a pharmaceutical grade hemp-derived CBD oil that is called Ananda Professional, so it’s only in the practitioner market and professional market.

And there is a nice pharmacy locator if you want to go to talk to somebody and find out, “If I want to try this, is it going to interact with my medications and how do I use it and how do I dose it?” It’s a really good avenue to get those questions answered. Certainly better than getting CBD from the gas station, where they are not equipped to give medical advice.

DrMR:   Haha, yeah.

DrAC:   So I really like Ananda Professional for that reason. There’s a lot of education that goes behind the pharmacies that carry it.

DrMR:   Awesome.

View Dr. Ruscio’s Additional Resources

Episode Wrap-Up

And as we move towards a close here, is there anywhere you want to point people to online: website, article, book?

DrAC:   I would tell them to go to anandaprofessional.com if they have questions on efficacy or how to talk to patients or if they’re consumers themselves about CBD. And they can even use the pharmacy locator to go speak to somebody who’s knowledgeable about that in their area. And if they’re looking for a broader discussion on cannabis, Americans for Safe Access is a good website.

DrMR:   Great. Yeah, I totally agree that we need to have smart people having these conversations. I’m sorry to the audience if I keep making this criticism, but I just see so many people online who are good at marketing and they know nothing about science. And when you go online and you search, the garbage product comes up first, because they learned how to market it the best. It may not necessarily be the most scientifically valid.

So anything we can do to help point people to where they can find measured opinions that are based upon science is a huge win in my mind. Thank you for those recommendations and also for the work that you’re doing. It’s really nice to speak with someone who is excited about this, but also is evidence-based and not going to make any speculation that’s just far too excessive, so I appreciate it.

DrAC:   Thank you. Yes, I would consider myself cautiously optimistic.

DrMR:   Yes, well said.

DrAC:   Thank you for having me.

DrMR:   Yeah, it’s been a pleasure chatting. Are there any parting words that you want to leave people with?

DrAC:   One thing—if you are interested in trying this or recommending it to patients—is just make sure that you are finding a product that has transparency and quality assurance. This is not FDA-regulated and it will be some time before that happens. So you can literally slap whatever you want on a label and not necessarily back that up with the contents. So this is self-regulated right now and our company is doing it the right way.

To find that, ask for a certificate of analysis, look at the lot number and make sure it matches, and just make sure that there’s tests for potency and purity that are readily available. I know that’s frustrating and makes extra work, but at least you’re not wasting your money and at worst, putting something in your body that you don’t want in your body.

Ananda Professional, for example (and there are other companies that do this) has a QR code on all of their products. If you scan that and put in the lot number, you will find a potency and purity, and traceability testing by an independent third-party lab on every product, and that should really be the norm. It’s unfortunately the exception right now, but I think as consumers and providers, if we demand more transparency and quality assurance, the industry will have to respond.

DrMR:   That’s great. So they just scan the QR code and that provides them with the summary? Or do they have to punch in a number from the bottle?

DrAC:   They do have to punch in the lot number, because we make different lots, so we have to test each of them. We do it for each lot.

DrMR:   That’s still pretty darn easy.

DrAC:   Yeah. And the lot number is right next to the QR code. So look for products that are doing that and just buy products that are transparent.

DrMR:   Awesome. We just went through a review of some of the data regarding probiotics and less than 50% of probiotics on the market in this analysis met their label claims. So yeah, we have to be careful with what we buy. We also want to be careful, as I’ve said before in the podcast. It doesn’t mean the most expensive thing is always the best. We want to be careful of that, but quality assurance to a reasonable degree does definitely matter.

DrAC:   Yeah, and it costs money to do those tests too. One last thing, there is a study in JAMA that 70% of CBD products don’t match their label. That was published in 2017. I think it’s gotten a little bit better, but again, exactly what you’re saying. So just do your due diligence.

DrMR:   Yeah. Well, there you go, folks, some very practical and reasonable advice on CBD. Alex, it’s been a pleasure chatting. Thank you again for taking the time.

DrAC:   Thank you very much.

What do you think? I would like to hear your thoughts or experience with this.


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