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 Cannabidiol or CBD oil has become increasingly popular in the United States as a remedy for a variety of ailments. Many older adults have also embraced CBD to treat everything from depression to chronic pain.

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

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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

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

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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

10 Potential Health Benefits of CBD for Older Adults

Cannabidiol or CBD oil has become increasingly popular in the United States as a remedy for a variety of ailments. Many older adults have also embraced CBD to treat everything from depression to chronic pain.

Cannabidiol, otherwise known as CBD, is derived from the Cannabis sativa plant, also known as marijuana or hemp. More than 80 chemicals called cannabinoids have been identified in the Cannabis sativa plant. THC, the chemical that causes a “high,” is the active ingredient in marijuana. However, cannabidiol is most often obtained from hemp, and contains just trace amounts
of THC.

There have been few side effects noted in CBD use studies, but they do occur and can include dry mouth, diarrhea, reduced appetite, drowsiness and fatigue. CBD can also interact with other medications, such as blood thinners.

The benefits of CBD are increasingly being researched and documented. Here are 10 areas in which CBD use has potential benefits for seniors.

1. Anxiety

CBD may have the potential to help manage anxiety. Researchers think that it might change the way that the brain’s receptors respond to serotonin, which is closely associated with mental health outcomes. In one study, social anxiety sufferers were able to give a speech more easily with the help of CBD. Additionally, research done with animals has shown decreased expression of anxiety with CBD. CBD can help promote stress reduction and lead to fewer physiological effects from anxiety, like increased heart rate.

2. Neurodegenerative Disorders

CBD might be a promising product in the fight against neurodegenerative diseases. A loss of neurons in different parts of the nervous system leads to a corresponding decline in cognitive and motor functions; these conditions, such as Parkinson’s, dementia and stroke, cause the brain and nerves to deteriorate over time. Researchers are actively studying brain receptors to uncover the ways that CBD could help.

We discussed how CBD can lower inflammation. Because inflammation can actually make neurodegenerative symptoms worse, CBD can promote good brain health through this mechanism, too. Keep an eye out for more studies to come on this subject. CBD could evolve to become a useful tool to turn to in the fight against neurodegenerative diseases.

3. Mental Health & Mood-related Disorders

As people age, they experience major changes as a result of getting older. Health usually declines and people are more likely to deal with loss and grief. Additionally, social isolation, depression and loneliness may all play a factor in decreased mental health. CBD has been shown to help with these and other related conditions. CBD may interact with brain receptors that are involved in mood regulation. CBD can promote stress reduction, mindfulness and improvement in cognitive function. This powerful combination can strongly contribute to how the mind perceives its situation while enhancing mood.

4. Sleep Quality

Sleep issues and insomnia challenge many individuals, and older adults are no exception. This may be caused by changes in sleep patterns as individuals age. Additionally, medical conditions and prescribed medications further complicate things.

Prescription sleep medications can be effective. However, their use comes with long-term concerns. They may lead to dependence, addiction and even worse sleep quality over time.

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CBD can help promote calmness and relaxation. Higher quality sleep can be the end result. This can be a natural way to lead to more regular and helpful sleep for older adults. Plus, it can reduce the need to take prescription sleep medications.

5. Pain Management

Around half of the older adult population lives with arthritis. Compared to traditional pain medications, CBD can be a compelling alternative as a natural and potentially safer remedy. Studies have indicated that CBD can reduce inflammation while alleviating pain. Conditions improved include joint pain, arthritis and multiple sclerosis.

6. Bone Health

Keeping bones healthy can be a challenge, especially for seniors living with osteoporosis. Bones become more fragile and vulnerable over time, making them more prone to breaking. For these reasons, seniors often experience significant pain and a propensity for fractures when falls occur. In addition to reducing inflammation and promoting cell repair, research shows that CBD may aid in strengthening bones. It can also promote the body’s ability to heal. While more research is needed, results in this area so far are promising.

7. Addiction & Dependence

When older adults are confronted with an illness, prescribed medication will usually follow. Tolerance may build for many medications that are taken over time. In some cases, addiction or dependence can be the end result. This can cause permanent damage to the body.

CBD has been shown to alleviate some conditions that involve opioids, generally without significant side effects. On top of that, CBD can aid in combating developed dependencies that grew out of the use of prescribed medications. It appears that CBD has the potential to help fight relapses and assist in overcoming withdrawals that develop during this time.

8. Heart Health

Heart disease is the leading cause of death for older adults. A top contributor to heart disease is high blood pressure. CBD has shown to be very promising as an alternative and natural treatment for high blood pressure. One recent study determined that it lowered the resting blood pressure of the study’s participants.Additionally, researchers administered stress tests and found a positive stress response in individuals evaluated in the study. Another study suggests that antioxidant properties of CBD can aid in lowering cardiac inflammation and deter the death of related cells that results from oxidative stress.

9. Cancer Treatment

CBD may help alleviate the symptoms of cancer along with the side effects stemming from treatment. In fact, CBD has shown a reduction in tumor growth in animals. It may even help the body absorb medications better or increase their potency.

Here, CBD may positively manage inflammation and change how cells can reproduce. CBD could also have the capacity to inhibit the growth of some types of tumor cells and stem their ability to reproduce efficiently.

10. Appetite Stimulation

A major health concern for seniors is malnutrition due to loss of appetite, whether due to medicaiton or age. This can lead to unnecessary and unwanted weight loss, muscle and tissue weakness, and other health issues. Marijuana has been studied extensively in this area, and is proven to enhance appetite in its users. CBD can stimulate appetite as well, according to some studies. In this way, it can be beneficial for seniors combating malnutrition and appetite loss.

Conclusion

Scientific research takes time and effort. With a broad range of CBD brands exploding on the market and the potential health benefits of the product coming to light, researchers have only just begun to scratch the surface on the ways that cannabinoids can promote wellness in seniors. In early studies, CBD has been shown to be very promising in improving a variety of ailments and conditions.

CBD is readily available over the counter in many forms. Older adults should talk to their doctor, pharmacist or home health provider before starting a CBD regimen. It’s important to determine if CBD treatment is the right option and make sure that no drug interactions or concerns exist. Also the stigma of marijuana and CBD use can be powerful; family members or the physician may harbor some negative associations to CBD and related products. Home health providers can step in to advocate for their patients who wish to use CBD to manage pain or anxiety. Providing educational materials and promising research on CBD to family members and skeptics should be a goal if you are offering CBD as an option in a home health regimen.

Brett Shay is the CEO of CareBridge Academy, a certified nurse aide and home health aide training school located in Philadelphia. He also leads Chosen Family Home Care, which is one of the nation’s only agencies dedicated to addressing the needs and challenges of the LGBTQ community and provides culturally competent care to the diverse local population.

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