Is the public using cannabidiol (CBD) to treat diagnosable conditions that have evidence-based therapies?
In this 2020 case series of 376 posts on a CBD forum on Reddit, most users reported taking CBD as a therapeutic for diagnosable conditions, including mental health, cardiological, dermatological, gastroenterological, ophthalmological, oral health, and sexual health conditions, many of which have other evidence-based treatment regimens.
Use of cannabidiol (CBD) has markedly increased in the past 5 years, concurrent with marketing claims that over-the-counter CBD can be used to treat almost any health condition. However, the reasons why individuals use CBD remain unclear.
The Growth Of CBD
Since 2014, the popularity of products containing the cannabis-derived chemical compound cannabidiol (CBD) has exponentially increased in all 50 US states. This increase in popularity was concurrent with marketing claims that over-the-counter CBD can be used to treat almost any health condition, including acne, anxiety, and menstrual problems. At present, however, the only US Food and Drug Administration (FDA)–approved CBD-derived therapy is Epidiolex to treat Lennox-Gastaut syndrome and Dravet syndrome (2 rare forms of childhood epilepsy). Although other therapeutic applications of CBD have promise, at present, use of CBD to treat other conditions is not recommended by the FDA.
Because of CBD marketing claims, the FDA has expressed concern by stating that “unsubstantiated therapeutic claims [are] a violation of the law [and] can put patients at risk.” However, the regulatory response of the FDA has been slow, with only a few warning letters issued and no other major actions taken. In congressional testimony, the FDA commissioner stated the agency would take stronger and wider-ranging actions if patients with diagnosable conditions were using CBD as a substitute or adjunct for approved therapies. Delayed regulatory action may in part result from the lack of available data documenting the reasons why consumers are using CBD-containing products.
To fill this knowledge gap and inform regulatory decision-making, we analyzed testimonials posted on a social media website by self-identified CBD users as part of a case series study. Although the typical methods of assessing reasons for using a product are based on surveys with active users, no surveys of CBD use among US consumers currently exist, to our knowledge. Surveys can be costly and time-consuming to field and always require some formative data to inform their need and, if necessary, their questionnaire design. Large groups of CBD users are gathering on social media to openly discuss why they use CBD, including on Reddit, a social media website with 430 million monthly users that is divided into topically focused forums termed subreddits. By reading these ongoing conversations, researchers can assess why the public uses CBD. Herein, we sampled posts from the subreddit r/CBD in which registered individuals publicly discuss their experiences using CBD and thematically analyzed the content of their posts to identify self-reported CBD users as well as any treatment applications they describe.
Results of The Study
Posts to r/CBD increased from 1973 posts in 2016 to 6234 in 2017, 13 752 in 2018, and 11 602 during January through August 2019 (Figure). Using the random sample of r/CBD posts, we estimated that 12.1% (95% CI, 11.0%-13.4%) of all r/CBD posts were authored by individuals who provided testimonials of their use of CBD. Of the 376 posts labeled as testimonials, 90.0% (95% CI, 86.8%-92.8%) of testimonials included at least 1 claim that CBD could treat a diagnosable condition, whereas 29.5% (95% CI, 24.8%-34.2%) included at least 1 claim of a wellness benefit.
Psychiatric conditions were the most commonly cited diagnosable condition, mentioned in 63.9% (95% CI, 59.0%-69.1%) of testimonials (Table 2), including “after using CBD for 2 months, my autism symptoms have improved.” The second most commonly cited subcategory of diagnosable conditions was orthopedic conditions (26.4%; 95% CI, 21.8%-31.1%), followed by sleep (14.6%; 95% CI, 11.3%-18.5%), neurological (6.9%; 95% CI, 4.4%-9.6%), and gastroenterological (3.9%; 95% CI, 1.9%-6.1%) conditions. Addiction (including opioid withdrawal), cardiology (including arrhythmias), dermatology (including acne), oral health (including canker sores), ophthalmology (including vividness of color perception), and sexual health (including erectile dysfunction) were cited in fewer than 2.0% of all testimonials.
Among applications of CBD for wellness, mental wellness predominated, mentioned in 29.5% (95% CI, 24.2%-34.4%) of testimonials, including “CBD has helped me to quiet my racing thoughts.” Physical wellness was cited in 1.4% (95% CI, 0.3%-2.8%) of testimonials, including “CBD has given me more energy.”
The CBD Discussion
The public has increasingly taken to the social media platform Reddit to discuss CBD, with a increase in the rate of monthly posts that mirrors the increase and trajectory of popular interest in CBD. A large fraction of these posts were authored by CBD users who described their own experience using CBD, and most of these testimonials cited taking CBD as a therapy for a diagnosable medical condition.
Although many potential therapeutic uses of CBD remain to be explored, our findings suggest that the public already perceives CBD as an effective therapeutic for many health conditions in ways that are potentially detrimental to public health. Because CBD is not an FDA-approved treatment for nearly all the conditions cited by users who post to Reddit, CBD users may unnecessarily experience prolonged illnesses that would otherwise be alleviated with proven effective treatments. In addition, CBD use is not devoid of health risks, with known risks including liver damage and male reproductive toxic effects as well as potential drug interactions that may be associated with adverse events or diminished efficacy of approved therapies and additional unknown health risks. However, the pharmacology of CBD has not been well studied; thus, little is known about both the potential therapeutic benefits or the risks of short- or long-term use.
The known and unknown risks of CBD use may be exacerbated by regulatory challenges that add context to our findings. For instance, products labeled as CBD often do not contain CBD or are mislabeled and sometimes contain psychoactive agents (eg, Δ9-tetrahydrocannabinol) not suitable for the treatments being sought by users. Moreover, CBD products may contain hazardous adulterants. For instance, nearly half of the hospitalized patients in the recent e-cigarette or vaping product use–associated lung injury outbreak vaped CBD-containing e-liquids, and other mass poisonings have been linked to synthetic cannabinoids. In these events, there is currently no track-or-trace infrastructure in which batches can be sourced and removed from the CBD supply chain. These dangers demand regulatory actions governing when, where, and how all CBD is sold, consistent with past sworn testimony by the FDA director.
Clinicians could also play an important role in patient safety regarding CBD. Considering that some patients may use CBD for unexpected treatment applications (eg, heart palpitations), clinicians across specialties should inform patients that over-the-counter CBD is not an approved or recommended treatment and offer opportunities for patients to obtain efficacious treatments, as well as explain that CBD use may not be risk free. Such conversations could also provide an opportunity to identify unexplored conditions that could benefit from proven treatments.
Public health professionals should also provide accurate information. Substantial debate about erroneous health information has occurred, but few cases beyond vaccine refusal exist. Our findings suggest a need for accurate information about CBD. For instance, additional surveillance of CBD use that overcomes the limitations of this study seems warranted. Leaders could also begin curation campaigns, with experts participating in ongoing social media conversations and mass media campaigns providing evidenced-based CBD information.
The Conclusion About CBD Use
The findings of this case series suggest that the public may already perceive CBD as an effective therapeutic for many health conditions. We believe this misperception warrants a multipronged response encompassing regulation, clinical practice, and health education. For example, regulators could enforce rules on market practices that may result in CBD being used to treat diagnosable conditions. Health care professionals could engage patients on their potential CBD use and redirect them to proven evidenced-based medicines. Public health agencies could run informational campaigns that encourage the public to seek treatment advice from health care professionals in lieu of CBD and provide vetted information on the limited proper uses of CBD for therapeutic benefit.