Cannabidiol prescription in clinical practice: an audit on the first 400 patients in New Zealand
Graham Gulbransen, MBChB, FAChAM, FRNZCGP1*, William Xu2, Bruce Arroll, MBChB, PhD, FRNZCG
BJGP Open, 2020, 1-8
DOI : 10.3399/bjgpopen20X101010
Background : Cannabidiol (CBD) is the non- euphoriant component of cannabis. In 2017, the New Zealand Misuse of Drugs Regulations (1977) were amended, allowing doctors to prescribe CBD. Therapeutic benefit and tolerability of CBD remains unclear.
Aim : To review the changes in self- reported quality of life measurements, drug tolerability, and dose- dependent relationships in patients prescribed CBD oil for various conditions at a single institution.
Design & setting : An audit including all patients (n = 400) presenting to Cannabis Care, New Zealand, between 7 December 2017 and 7 December 2018 seeking CBD prescriptions
Method : Indications for CBD use were recorded at baseline. Outcomes included EuroQol quality of life measures at baseline and after 3 weeks of use, patient- reported satisfaction, incidence of side effects, and patient- titrated dosage levels of CBD.
Results : Four hundred patients were assessed for CBD and 397 received a prescription. Follow- up was completed on 253 patients (63.3%). Patients reported a mean increase of 13.6 points (P<0.001) on the EQ- VAS scale describing overall quality of health. Patients with non- cancer pain and mental- health symptoms achieved improvements to patient- reported pain and depression and anxiety symptoms (P<0.05). There were no major adverse effects. Positive side effects included improved sleep and appetite. No associations were found between CBD dose and patient- reported benefit.
Conclusion : There may be analgesic and anxiolytic benefits of CBD in patients with non- cancer chronic pain and mental health conditions such as anxiety. CBD is well tolerated, making it safe to trial for non- cancer chronic pain, mental health, neurological, and cancer symptoms.
How this fits in
CBD prescription in primary care was legalised in New Zealand in 2017. Previous preclinical trials have shown CBD to have anxiolytic and anti- inflammatory properties but there remains a paucity of studies investigating its therapeutic potential. In this quantitative observational study of the first 400 patients prescribed CBD in New Zealand, CBD was well tolerated amongst patients with a wide range of conditions and symptoms. Quality- of- life benefit was experienced to a greater degree in patients living with non- cancer chronic pain and anxiety- related mental- health conditions, and to a lesser degree in patients with cancer or neurological symptoms.
With the amendment of the New Zealand Misuse of Drugs Regulations 1977 in 2017, CBD has become a legal prescription medicine. The amendment recognises the right of New Zealand doctors to prescribe CBD products that contain no more of 2% of 9-Δ-tetrahydrocannabinol (9-Δ-THC) in the product.1CBD and 9-Δ-THC are cannabinoids, active compounds found within the Cannabis genus of plants.2 While 9-Δ-THC is the main psychoactive component responsible for euphoria and the ‘high’ associated with marijuana, CBD is the non- euphoriant component.2,3CBD is currently FDA- approved for the treatment of Dravet and Lennox- Gastaut syndrome, two childhood seizure disorders.4 Randomised controlled trials (RCTs) have shown that, when CBD is added to existing anti- epileptic medication in patients with these syndromes, seizure frequency decreases.5,6However, CBD shows potential therapeutic use beyond this. Pre- clinical studies demonstrate that CBD has potential anti- inflammatory effects via inhibition of immune cell migration, which may be useful in chronic inflammatory conditions.7Moreover, preclinical studies have demonstrated anxiolytic effects of CBD.3,8–10 Crippa et al found that in patients with generalised anxiety disorder given 400 mg of oral CBD, there was decreased cerebral blood flow to anxiety processing areas of the brain and a decrease in patient- reported anxiety when compared to placebo.8 CBD in one double- blinded placebo- controlled RCT decreased symptoms of social anxiety disorder patients and fear of public speaking.10 CBD may also reduce psychotic symptoms of schizophrenia.11CBD appears to be safe for patients, with a recent phase I dosage trial showing purified CBD oil is well tolerated up to doses of 6000 mg.12 However, due to a paucity of clinical studies, prescribing guidelines are lacking.The aim of this study was to conduct a clinical audit on the patient population referred to Cannabis Care (a primary care clinic in Auckland, New Zealand) for CBD oil. The authors explored the indications for prescribing CBD oil, patient quality of life, patient satisfaction, and self- titrated dosage levels.