Side Effects Of CBD Oil In The Elderly

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Cannabidiol Use in Older Adults ABSTRACT: Cannabidiol (CBD) is a nonpsychoactive component of the Cannabis sativa plant. CBD products, which have become popular in the United States, are CBD (Cannabidiol), an active compound found in cannabis has been proven to be effective in the treatment of ailments associated with elderly people such as Alzheimer’s disease, arthritis, dementia and even depression. CBD is being studied as a treatment for a wide range of conditions. Find out more about how CBD can help you and what risks to consider.

Cannabidiol Use in Older Adults

ABSTRACT: Cannabidiol (CBD) is a nonpsychoactive component of the Cannabis sativa plant. CBD products, which have become popular in the United States, are frequently used to treat pain, anxiety, and sleep disorders—conditions that affect older adults. Evidence is insufficient to recommend the use of CBD for these disease states. OTC CBD products are widely available, and there are significant concerns regarding their safety, including mislabeling, standardization issues, and drug interactions. The informed pharmacist will be a valuable resource for discussing the use and safety of CBD with older adults.

Cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC) are among the many cannabinoids, or components, of the Cannabis sativa plant. CBD is nonpsychoactive, whereas THC has psychoactive properties such as euphoria and psychosis. Two common strains of Cannabis sativa are marijuana and hemp. 1 CBD may be derived from either marijuana (which often contains more than 15% THC) or hemp (having a THC concentration of no more than 0.3%). 2 In addition, CBD may be extracted from Cannabis indica and hybrid plants, which may have higher concentrations of CBD than THC. A recent survey revealed that one in seven Americans uses CBD products, with the most common reasons for its use being pain, anxiety, poor sleep, and arthritis. 3

Endogenous cannabinoids and phytocannabinoids such as CBD and THC modulate the endocannabinoid system (ECS). THC is a partial agonist on the cannabinoid (CB) 1 receptor that results in central nervous system (CNS) effects, such as the “high” associated with marijuana; it also has limited CB2 agonist activity in the immune system. CBD has minimal activity on CB receptors, but it affects the ECS and the non-ECS. 4 Some of the proposed mechanisms of CBD include agonist activity at serotonin 1A, transient receptor potential vanilloid 1, G protein–coupled receptor 55, and adenosine A2A receptors, which may explain some of the possible analgesic, anti-inflammatory, anxiolytic, and antiepileptic effects of CBD. 1,5

In the United States, about two-thirds of states have legislation approving cannabis for recreational use (11 states) and/or medicinal purposes (21 additional states). Seven states mandate pharmacist involvement, such as dispensing activities or consulting to dispensaries. 6 The only FDA-approved (in 2018) CBD product is Epidiolex, which is indicated for treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome. 7 The law prohibits the sale of foods or dietary supplements to which CBD has been added; however, a wide variety of products containing CBD are available at retail stores. 8

Formulations

CBD formulations used in clinical trials include oral capsules, sublingual spray, oil-based solution, and topical gel. OTC CBD products are available in numerous other formulations, including topical balms and creams, e-liquid for inhalation, and infused foods and drinks. 1,9 Given the many formulations and manufacturers, nearly all CBD products lack standardization. The exception is Epidiolex, which is available as an oil-based oral solution formulated with sesame oil and standardized to contain 100 mg/mL of pure CBD extract. 7

CBD levels in commercially available products vary widely. The FDA has issued warning letters every year since 2015 to companies marketing unapproved new drugs that allegedly contain CBD. 8,10-13 As part of these warnings, the FDA tests the chemical content of CBD compounds, and it has found that many products do not contain the claimed level of CBD. Commercially available products have been assessed in laboratories, whose findings support the FDA’s concerns about product inconsistency and mislabeling. A laboratory assessment of OTC CBD products sold in the U.S. demonstrated that only 26 of 84 (31%) products tested were accurately labeled. 14 Not only was the amount of CBD in products overlabeled or underlabeled, but 21% of products contained THC even though it was not listed in the product information. In addition, the FDA has cited concerns regarding reports of contaminants such as pesticides and heavy metals. 8

The mislabeling of CBD products results in dosing uncertainty in the use of any commercially available OTC product. This is an important caveat in the extrapolation of dosages used in clinical research. In such research, a range of dosages have been used for different indications and routes of administration. For example, Epidiolex oral solution is approved for weight-based dosing from 5 mg/kg/day to a maximum of 20 mg/kg/day. 7 CBD has been given orally at dosages of 100 mg to 800 mg. 15,16 CBD topical gel has been used for fragile X syndrome at a dosage of 50 mg to 250 mg daily. 17 For smoking cessation, a CBD metered-dose inhaler has been administered at a dosage of 400 mcg as needed. 18

Administration and Absorption

CBD absorption depends on the product formulation. In animal and human studies, CBD administered orally has been shown to be poorly absorbed, with bioavailability of 13% to 19%. 19,20 CBD’s bioavailability is believed to be reduced by first-pass metabolism. Poor bioavailability can be avoided with the use of alternative formulations. There is an emerging market for novel delivery methods to increase CBD’s oral bioavailability. 21

Absorption of CBD may also be altered by food intake. In clinical trials, coadministration of Epidiolex with a high-fat, high-calorie meal increased plasma levels of CBD fourfold to fivefold compared with administration on an empty stomach. 7 In one study using a purified (99%) CBD capsule, coadministration with food resulted in a maximum concentration and AUC of 14-fold and fourfold higher, respectively, compared with administration on an empty stomach. 22 CBD inhalation in humans has an average bioavailability of approximately 31%, with the use of one type of metered-dose inhaler demonstrating bioavailability of more than 65%. 18,23 Transdermal absorption of CBD is variable in animal studies and has yet to be fully elucidated in humans. 4

CBD Uses

CBD is FDA-approved for certain types of seizure disorders; for more information, see the manufacturer’s website for Epidiolex (www.epidiolex.com). The following section will focus on the common reasons for off-label CBD use, including pain, sleep disorders, and anxiety, all of which affect older adults.

Pain: An estimated 50 million American adults (20.4%) experience chronic pain, with persons aged 65 years and older constituting 61.2% of those affected. 24 Much of the data on chronic pain (e.g., neuropathic pain, cancer pain, diabetic peripheral neuropathy, fibromyalgia, HIV-associated sensory neuropathy, spasticity associated with multiple sclerosis [MS], and rheumatoid arthritis) involve the use of marijuana and cannabinoids (often THC, combination THC-CBD, or nabiximols [a specific mixture of THC, CBD, other minor cannabinoids, flavonoids, and terpenes]). Formulations used in pain studies range from smoked, oral, or oromucosal spray of THC; synthetic cannabis (nabilone); synthetic THC (dronabinol); and vaporized cannabis, with results suggesting modest reductions in pain and spasticity. 25

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Sativex (nabiximols), an oromucosal THC-CBD spray, is approved in several European countries for treating symptoms of moderate-to-severe spasticity associated with MS, and a phase II/III clinical trial is currently under way in the U.S. to evaluate nabiximols for advanced cancer pain with inadequate analgesia from chronic opioids. 26 There is a paucity of data on CBD used for pain; most studies are in preclinical stages. 5,25,27

Sleep Disorders: Sleep disorders are disproportionately more prevalent in older adults. 28 Patients have commonly reported that cannabis is helpful for sleep. 29 CBD is used for alleviation of insomnia, but little is known about its effectiveness. One study that compared CBD with placebo for insomnia in 15 patients suggested that 160 mg of CBD may improve sleep duration without next-day sedation. 30 Somnolence was reported in nearly one-third of patients taking Epidiolex in clinical trials, which provides additional support for CBD’s benefits for sleep in some patients. 7 However, more research is needed to determine whether CBD is useful for individual components of insomnia, such as sleep latency, wakefulness after sleep onset, sleep duration, and overall sleep quality.

Anxiety: Evidence is not strong for the use of CBD for anxiety disorders. CBD has demonstrated some benefit for social anxiety disorder and social phobia when patients undergo a simulated public-speaking test. 31,32 However, these trials had small sample sizes and study biases. It is theorized that CBD could be beneficial for anxiety based on its mechanism of action at the serotonin receptor. 31

Other Disease States: Data on the use of CBD for various other conditions are mixed, and evidence is insufficient to recommend this practice. The efficacy of CBD has been studied in bipolar disorder, Crohn’s disease, diabetes, dystonia, fragile X syndrome, graft-versus-host disease, Huntington’s disease, opioid withdrawal, Parkinson’s disease, schizophrenia, and smoking cessation. 33 In addition, CBD has been reported to be useful for addiction, possibly by modulating dopamine and serotonin. 1

Adverse Effects and Safety

The use of CBD is considered “possibly safe” when used appropriately, based on some clinical evidence. 33 However, insufficient high-quality data exist to recommend CBD for most older adults. The most common adverse effects associated with CBD, reported in clinical trials of Epidiolex, are somnolence (~32%), decreased appetite (16%-22%), diarrhea (9%-20%), and increased liver-function tests (13%). 7 Other side effects are orthostatic hypotension, lightheadedness, and dry mouth. Adverse effects appear to be dose-related. The safety of CBD in the geriatric population has not been fully clarified, and Epidiolex clinical trials did not include patients older than 55 years. 7

There are practical concerns regarding CBD use in older adults. The geriatric population may be more susceptible to adverse effects of CBD commonly seen in younger adults, including sedation. CBD is hepatically metabolized, predominantly via CYP2C19 and CYP3A4. 4 Older adults with reduced hepatic function may be more susceptible to adverse effects of CBD.

Commercially available CBD products may not contain the CBD concentrations claimed on the label, and the FDA warns consumers to be aware of this inconsistency when using such products. 13 Of particular concern is the THC component in mislabeled CBD products. Older adults may be predisposed to adverse effects caused by the psychoactive properties of THC. The use of marijuana in older adults has been associated with increased risk of injury and adverse events. 34

Drug-Drug Interactions

CBD has been shown to inhibit hepatic enzymes. 4 In human studies, coadministration of CBD with antiepileptic drugs resulted in increased concentrations of drugs that are substrates of CYP2C9, CYP2C19, and CYP3A4. 35 Given CBD’s known sedative effect, there is also a theoretical concern for additive hypnotic reactions in combination with CNS depressants. TABLE 1 lists potential interactions with CBD.

The Pharmacist’s Role

A recent survey by the Arthritis Foundation revealed significant use of and interest in CBD for arthritis. The Foundation acknowledges the possible efficacy of CBD for treating pain, insomnia, and anxiety while also recognizing the lack of rigorous clinical studies. 36 Despite a scarcity of evidence for CBD use in the geriatric population, education on known and potential benefits and risks is vital to a patient’s decision-making process. The pervasive direct-to-consumer advertising and ubiquity of CBD products may foster misinformation or misinterpretation of actual evidence. The pharmacist should be prepared to give an unbiased assessment of CBD, including concerns about product mislabeling, underlabeling and overlabeling of CBD, and lack of THC labeling in a product containing it.

The pharmacist should consider patient-specific factors when discussing CBD use. A review of potential drug-drug interactions is warranted prior to using CBD. Counseling on pharmacokinetic variables, such as oral administration with or without food, may be relevant. Comorbidities may also be pertinent to the discussion, and safety concerns should be reinforced. For example, a patient with preexisting respiratory disease should avoid inhalation as the route of CBD administration. An honest and impartial discussion will facilitate a stronger patient–healthcare provider relationship.

If a patient has decided to use CBD, the pharmacist can direct the patient toward a top-quality CBD product. TABLE 2 provides questions to consider when recommending a CBD product. Given the increasing number of states and U.S. territories legalizing marijuana for medicinal or recreational use, the informed pharmacist will be a valuable resource for discussing the use and safety of CBD with older adults. 6

CBD Oil for the Elderly and Older Adults: Benefits & Uses

The Cannabis Sativa plant has at least 104 chemical compounds—also referred to as cannabinoids—of which cannabidiol (CBD) is a notable one. Unlike tetrahydrocannabinol (THC), CBD isn’t intoxicating as it does not give the highly stimulating feeling that cannabis is known for.

CBD has a wide range of properties that are being studied for their potential clinical benefits. Certain studies show that CBD could be helpful in a wide range of conditions, such as pain, inflammation, epilepsy, anorexia, schizophrenia, and more.

CBD oil is a liquid extract that’s usually derived from hemp. It is typically extracted with pressurized CO2 and then infused into carrier oils, such as MCT oil, hemp seed oil, or olive oil.

You can find CBD oil over the counter in many countries. Hemp-derived CBD oil is legal in all 50 states and you don’t need a prescription to buy it.

Moreover, CBD oil can be useful in certain conditions affecting older people. As such, it’s essential to determine exactly how helpful it is in treating these conditions and how to use it to minimize side effects and other potential health risks.

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What Are the Different Types of CBD Oil?

CBD oils have three main variants based on chemical composition. These variants are CBD isolate, full-spectrum CBD oil, and broad-spectrum CBD oil.

CBD Isolate

This is the purest form of CBD, having no tetrahydrocannabinol (THC) content or other hemp compounds. The isolate is usually found in a crystal or powder form of CBD and is cheaper than the other variants.

Full Spectrum CBD

Full-spectrum CBD contains other cannabinoids that occur in the cannabis plant — also known as whole-plant CBD — including trace amounts of THC. Full-spectrum CBD has been shown to have more medicinal benefits than the other variants as it evokes the entourage effect — a mechanism where all cannabis compounds work together in synergy to amplify each other’s effects.

Broad Spectrum CBD

The broad-spectrum CBD also has all the cannabinoids in the cannabis plant but doesn’t contain tetrahydrocannabinol. This variant is not as easily obtainable as the other versions, although the extraction process is similar to the other two.

How Effective Is CBD Oil?

In our bodies, the endocannabinoid system works to promote and maintain homeostasis — a state where everything functions optimally. It works irrespective of our external environment so that changes or fluctuations do not affect our normal body balance.

When that balance is breached, perhaps due to a sickness or injury, CBD oil helps the endocannabinoid system adjust so that it can resolve the problem faster and more optimally. CBD oil achieves this by slowing down the breakdown of endocannabinoids already present in the body.

This allows the body to use them longer and regulate balance more efficiently in all other systems throughout the body.

How Safe Is CBD Oil?

CBD oil has shown itself as a rising and promising treatment for older people.

It provides an alternative for older adults who are prescribed medical marijuana by their doctors. Medical marijuana is legal in some states, but some older people would prefer not to experience the buzz when taking their medicine.

CBD does not intoxicate or produce a feeling of euphoria when used; however, this is also dependent on the THC content.

CBD is usually tolerated by most people with very few side effects. A consultation with a holistic doctor experienced in CBD use will help you get a bigger picture of the pros and cons of your treatment.

Speaking of which…

What Are the Health Benefits of CBD Oil for Seniors?

There are several health benefits of CBD oil. Although research is still in development, certain studies show that CBD might become an alternative treatment option for seniors with different health conditions, such as:

1. Arthritis

Arthritis is one of the major causes of disability in the United States.

Recent reports from the Arthritis Foundation have shown that two of the most common types of arthritis — rheumatoid and osteoarthritis — may be successfully managed with the use of CBD.

Further research has also shown that CBD helped in reducing pain, improving sleep, and reducing anxiety among arthritis patients.

Although not many clinical studies have been conducted, the arthritis foundation has urged the FDA (Food and Drug Administration) to regulate the use of CBD products such as tinctures and topicals for arthritic pain.

2. Chronic Pain

CBD can be used for pain management too. Its anti-inflammatory properties help in reducing joint pain associated with arthritis (1).

Its antioxidative, antiemetic, antipsychotic, and neuroprotective properties have made CBD a reliable option for many.

It can be used for health conditions such as lupus, nausea, post-traumatic stress, fibromyalgia, cancer pain, and even neuropathic pain.

3. Anxiety Disorders

Studies have confirmed that CBD may be an alternative solution for anxiety. A study carried out by the national institute on Drug Abuse (NIDA) showed that CBD helped in reducing stress in animals.

CBD has also been recommended for people with post-traumatic stress disorders and it can also be used to treat insomnia caused by anxiety.

On top of that, CBD can help with the following conditions:

  • Migraine
  • Depression
  • Sleep disorder
  • Alzheimer’s disease
  • Epilepsy
  • Post-traumatic stress disorder (PTSD)
  • Nausea
  • Lung conditions
  • Parkinson’s disease
  • Asthma
  • Cancer
  • Multiple sclerosis (MS)

Things to Consider Before Buying CBD Oil

You should consider certain factors such as safety, transparency of your vendor, and the product’s quality to avoid common mistakes when buying CBD Oil.

Here are a few important things to look for:

  • Certificates of Analysis (COA): this is the document that confirms the product’s chemical profile and the lack of contaminants, such as pesticides, heavy metals, and mycotoxins.
  • The company’s reputation can be determined based on reviews, warning letters from the FDA, health claims made by the company (if it is unsubstantiated or not), and its certification status.
  • MCT oil helps improve CBD’s absorption because CBD and other cannabinoids are fat-soluble.

In some countries, CBD oil is classified as a nutritional supplement rather than a drug. This makes it harder to know if it contains the exact quantities of cannabidiol, as regulation may be a bit lax.

Is CBD Oil Safe?

Although CBD oil can improve the quality of life of the elderly, it also comes with some benign side effects. Some of the risks associated with CBD oil include the following:

  • Dry mouth
  • Fatigue and Drowsiness
  • Diarrhea
  • Reduced appetite
  • Weight fluctuation

In addition to these side effects, there’s also a risk of CBD-drug interactions. Some medications come with a “grapefruit warning”. These are drugs that interact with even small quantities of grapefruit, affecting the enzymes that break down these drugs. CBD also affects these enzymes and, as such, should not be taken alongside these medications due to possible complications.

Drugs that shouldn’t be taken with CBD include:

  • Cholesterol medications (Statins)
  • High blood pressure medications
  • Heart rhythm medications
  • Anti-infection medications
  • Mood medications
  • Blood thinners
  • Pain medications
  • Erectile dysfunction and prostate medications
  • Organ transplant rejection medications
  • Crohn’s disease medications

Key Takeaways on the Benefits of CBD Oil for the Elderly

Old age comes with its own quirks as well. Lots of health conditions have been more prevalent among the older population. CBD has shown itself as a natural and safe alternative to pharmaceutical medications when it comes to addressing the problems linked to aging.

A good number of studies, surveys and other scientific evidence show that CBD does help in the treatment of conditions associated with seniors, such as pain, inflammation, arthritis, and even sleep disorders, and neurodegenerative conditions.

That said, it’s important you speak with your physician and do some research before you try any CBD oil product.

Do we have any seniors among our readers? Give us a shout in the comment section and tell us how CBD has improved your quality of life!

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References

  1. Zuardi AW. Cannabidiol: from an inactive cannabinoid to a drug with a wide spectrum of action. Rev Bras Psiquiatr. (2008).
  2. Campos AC, Moreira FA, Gomes FV, Del Bel EA, Guimarães FS. Multiple mechanisms are involved in the large-spectrum therapeutic potential of cannabidiol in psychiatric disorders. Philos Trans R Soc Lond B Biol Sci. (2012).
  3. Martin-Santos R, Crippa JA, Batalla A, Bhattacharyya S, Atakan Z, Borgwardt S, et al. Acute effects of a single, oral dose of d9-tetrahydrocannabinol (THC) and cannabidiol (CBD)administration in healthy volunteers. Curr Pharm Des. (2012).
  4. Schier A. R., Ribeiro N. P., Silva A. C., Hallak J. E., Crippa J. A., Nardi A., E., et al. . Cannabidiol, a Cannabis sativa constituent, as an anxiolytic drug. Rev Bras Psiquiatr. (2012).
  5. Bergamaschi MM, Queiroz RH, Zuardi AW, Crippa JA. Safety and side effects of cannabidiol, a Cannabis sativa constituent.Curr Drug Saf. (2011).
Nina Julia

Nina created CFAH.org following the birth of her second child. She was a science and math teacher for 6 years prior to becoming a parent — teaching in schools in White Plains, New York and later in Paterson, New Jersey.

What to Know About CBD Oil For Elderly

‌CBD is a chemical found in marijuana. CBD doesn’t contain the ingredient that produces a high, which is known as tetrahydrocannabinol (THC). Typically CBD is available as an oil, but CBD is also sold as an extract, a vaporized liquid, and an oil-based capsule. Numerous CBD-infused food, drink, and beauty products are available online.

Many people use CBD oil to curb symptoms of many common health issues, including some elderly people. According to a 2020 nationally representative Consumer Reports survey, 20% of Americans 65 years and older said they’d tried CBD oil, up from 14% from the prior year in 2019. However, it’s important to keep in mind what conditions CBD oil can help and whether it’s safe for the elderly to use.

Is CBD Oil Effective?

Each of us has something called an endocannabinoid system. The endocannabinoid system works to keep you in a stable condition where everything in your body works at its best. For instance, if it is hot outside or if you are exercising vigorously, your endocannabinoid system will help steady your heart rate and keep your body temperature within a healthy range by making you sweat.

Your body works best when everything is balanced, and your endocannabinoid system helps maintain that balance, despite what might be going on in your external environment.

When something is out of balance, like an inflamed joint due to arthritis or injury, CBD oil helps support your endocannabinoid system so your body can better handle and relieve the problem.

Is CBD Oil Safe for Seniors?

We need more research, but CBD oil seems to be an up-and-coming treatment solution for the elderly.

While CBD and THC are both found as parts of the cannabis plant, significantly higher THC amounts are found in marijuana. Some seniors might be prescribed medical marijuana by their doctor, although medical marijuana is not legal in every state, and some people don’t want to experience a “high.” In those cases, CBD can be a great alternative.‌

CBD doesn’t produce a high, and it’s legal throughout the United States. It’s sourced from a hemp strain of cannabis and contains .3% THC or less. This means you get all of the benefits without having to worry about feeling a high.

Benefits of CBD Oil

There are numerous benefits of CBD oil:

  • Relieves arthritis pain
  • Relieves chronic pain
  • Reduces inflammation
  • Reduces muscle spasms
  • Improves sleep
  • Prevents or reduces symptoms related to Alzheimer’s disease
  • May reduce cancer cell growth
  • Reduces nausea and vomiting for cancer patients being treated with chemotherapy

Pain relief. CBD oil has also proven to be an effective, non-habit-forming treatment for pain. One study found that CBD reduces pain 30% more than traditional medication or medical marijuana (THC) alone.

General anxiety and performance anxiety. One study of individuals with a social anxiety disorder and fear of public speaking gave some people a single dose of CBD an hour and a half before they participated in public speaking. Those given the CBD experienced a significant reduction in their anxiety, with less discomfort and stress.

In short, CBD has been proven effective in enhancing the quality of life, preventing cognitive decline, reducing blood pressure in stressful situations, and more.

What to Consider When Buying CBD

Decide why and what form. Think about what you’ll be using CBD for and how you’d prefer to use it. CBD is often available as an oil, pill, drop or lotion.

Consider the amount of THC. Some CBD products contain THC, although it’s in very small amounts. If you’re looking for CBD with no TCH in it at all, consider looking for CBD made from hemp.

Find where it was made. Not all CBD products are made the same way. Colorado has very robust, trusted CBD manufacturing facilities, but if you buy CBD online and it comes from somewhere overseas, it may not have gone through any safety testing.

Read the label. Always read the label of any CBD product to check for additional ingredients that could affect your health or safety.

Stay cautious. Some CBD brands will make claims that CBD can cure cancer or help with heart disease. Huge health claims like that are illegal and are not verified. If a brand is advertising unrealistic benefits, beware.

Risks of CBD Oil

Currently, the only CBD product approved by the Food and Drug Administration is a prescription oil called Epidiolex used to treat epilepsy. Although CBD is currently being studied as a potential treatment for other conditions like Parkinson’s disease, schizophrenia, multiple sclerosis, and diabetes, the research is limited.

CBD also carries some potential risks and may cause:

  • Dry mouth
  • Diarrhea
  • Tiredness and fatigue
  • Reduced appetite
  • Potential negative interaction with other medications

Because CBD is mostly available as an unregulated supplement, it is challenging to pinpoint effective doses or know exactly what you’re getting. For this reason, it’s important to talk with your doctor before taking CBD.

Show Sources

CBD Awareness Project: “Benefits of CBD.”

Consumer Reports: “A Guide to CBD and Cannabis for Older Adults”, “How to Shop for CBD.”

Journal of pain and symptom management: “Multicenter, double-blind, randomized, placebo-controlled, parallel-group study of the efficacy, safety, and tolerability of THC:CBD extract and THC extract in patients with intractable cancer-related pain.”

Mayo Clinic: “What are the benefits of CBD—and is it safe to use?”

Neuropsychopharmacology: “Cannabidiol Reduces the Anxiety Induced by Simulated Public Speaking in Treatment-Naïve Social Phobia Patients.”

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