THE AGRICULTURE IMPROVEMENT ACT OF 2018
In 2018, the Agriculture Improvement Act, also known as the
Farm Bill, completely changed the landscape for the sale of cannabinoid products in the United
States. This new bill defines hemp as Cannabis sativa and
any part of that plant, including the seeds thereof and all derivatives, extracts,
cannabinoids, isomers, acids, salts, and salts of isomers, whether growing or not, with a THC
concentration of not more than 0.3% on a dry weight basis. According to the Farm Bill,
cannabis (or what we commonly refer to as marijuana) is considered Cannabis sativa containing more than 0.3% THC. The Farm Bill made hemp and its
constituents, including CBD, exempt from the Controlled Substances Act and legal for sale
[1,2].
REVIEWING THE EVIDENCE: EFFICACY AND SAFETY
While it is unclear if smoking cannabis improves multiple
sclerosis-related symptoms, a prescription product available in Canada and most of Europe,
as well as other products containing the combination of THC and CBD, seem to reduce
spasticity in patients with multiple sclerosis. Nabiximols, a prescription oromucosal
spray containing whole-plant cannabis extract (Sativex), is available in most of Europe
and Canada but is not yet approved in the United States. Each actuation of this cannabis
extract spray is standardized to deliver THC 2.7 mg and CBD 2.5 mg [1].
REVIEWING THE EVIDENCE: EFFICACY AND SAFETY
Cannabis crosses the placenta, and use during pregnancy has
been associated with numerous negative maternal and fetal outcomes in observational
studies. THC is excreted into the breast milk for at least six weeks following cessation
of use and can cause delayed motor development in the infant [1]. Patients should be informed of these
risks and discouraged from using cannabis while pregnant or breastfeeding.
REVIEWING THE EVIDENCE: EFFICACY AND SAFETY
A prescription CBD solution approved by the FDA is labeled
for the adjunctive treatment of Lennox-Gastaut syndrome, Dravet syndrome, and tuberous
sclerosis complex. Prescription CBD is an oil-based oral solution standardized to contain
CBD extract 100 mg/mL in sesame oil. The extract is highly purified from a plant source.
Originally classified by the DEA as a Schedule V controlled substance, it was descheduled
in April 2020 [3].
REVIEWING THE EVIDENCE: EFFICACY AND SAFETY
Research on the use of CBD for mental health benefits is
inconclusive. In healthy patients, several small, low-quality studies show that oral CBD
15 mg or 150 mg modestly improves emotional exhaustion, depression or anxiety symptoms,
and the ability to cope with stress, when compared with standard care or placebo, but it
is not clear if CBD is beneficial in patients diagnosed with anxiety or depression [3].
REVIEWING THE EVIDENCE: EFFICACY AND SAFETY
Cannabidivarin is a nonpsychoactive cannabinoid with
structural similarity to CBD. The concentration of cannabidivarin is greater in Cannabis indica than in Cannabis
sativa. While cannabidivarin is structurally similar to CBD, it is the
biosynthetic precursor to tetrahydrocannabivarin, which results from the isomerization of
cannabidivarin under acidic conditions. Based on the available laboratory and animal
research, it seems to act through many of the same receptor pathways as CBD [4].
REVIEWING THE EVIDENCE: EFFICACY AND SAFETY
Although there is interest in using cannabigerol for
conditions such as cachexia, dyslipidemia, Huntington disease, and inflammatory bowel
disease, available research is limited to in vitro and animal studies. Some research shows
that the anti-inflammatory effects of cannabigerol might be greater when used in
combination with CBD, but cannabigerol also seems to reverse the antiemetic effects of CBD
when used concomitantly [7].
GENERAL SAFETY CONSIDERATIONS
According to data compiled from sources including the FDA,
the Centers for Disease Control and Prevention (CDC), and the American Association of
Poison Control Centers, some of the most common adverse effects associated with delta-8
THC include difficulty thinking and speaking, a dreamlike state, euphoria, feeling "high,"
and vision and time distortion. Serious safety signals also have been observed, including
Brugada ECG pattern and cannabinoid hyperemesis syndrome, frequently leading to emergency
room visits and hospitalization [9].
GENERAL SAFETY CONSIDERATIONS
The cornerstone of long-term treatment for CHS is complete
discontinuation of cannabis use, but benzodiazepines and capsaicin also may play a role in
short-term symptom management [10].
GENERAL SAFETY CONSIDERATIONS
There has been a recent uptick in accidental ingestion of
cannabis-containing edibles in children ages 12 years and younger. Legalization of
recreational cannabis and the availability of these more appealing food forms, like
gummies, are likely to blame. Accidental ingestion of cannabis-containing edibles in
children has been associated with ataxia, coma, hypotonia, hypothermia, lethargy,
nystagmus, respiratory depression, seizures, and tremors [1].
