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Research & Development Medical research, Neurology & psychology, Adverse effects

Managing Epilepsy With CBD

Pharmaceutical CBD is currently a restricted prescription medication in the US, and insurance coverage is often limited to those with specific approved indications.

Unsurprisingly, a large number of patients with epilepsy seek an alternative: either in the form of dietary CBD supplements sold by commercial vendors or less refined cannabinoid products, often containing THC. Despite the widespread availability of these cannabinoid products, controlled studies evaluating their safety or efficacy are rare. But now a study has made a compelling case for these alternative therapies as a means of improving quality of life. 

An observational cohort study of patients with epilepsy found those who used artisanal CBD products at baseline reported higher quality of life, lower psychiatric symptom severity, and improved sleep, as well as better health outcomes longitudinally, compared with participants who used no cannabis-based products. Though no group differences were observed in terms of seizure control, CBD users reported significantly better medication tolerability and used fewer prescription medications than controls. 

We spoke to the researcher behind the study to find out more. 

Q&A

Justin Strickland, Instructor at the Behavioral Pharmacology Research Unit in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, USA

Why did you choose to study all types of epilepsy?

This is actually one of the major strengths of the study; though CBD is currently approved for specific syndromes, it is possible (and likely) that more general benefits may be observed across different epilepsy types.

What constitutes an artisanal CBD product? 

Artisanal CBD products include those products available on the medicinal cannabis market other than pharmaceutical grade CBD products like Epidiolex. Given the costs or regulatory constraints in obtaining pharmaceutical CBD products, many patients with epilepsy elect to use alternative CBD products sold widely as dietary supplements by commercial vendors. Other patients also elect to use cannabinoid products that are less refined and include other phytocannabinoids and terpenoids found in cannabis, some of which contain THC in addition to or in lieu of varying concentrations of CBD.

Is there a preference for CBD products over whole flower/THC products in epilepsy patients more generally?

Though we did not measure a direct preference, in general, we found that most patients selected products rich in CBD as opposed to whole flower or THC products. This is consistent with other data showing that patients with epilepsy tend to self-select CBD-dominant products when seeking medicinal cannabis from commercial sources with the intention of treating epilepsy (2).

Is the mechanism behind the positive results seen in the CBD group understood? 

Some work has evaluated the behavioral and pharmacological mechanisms underlying CBD treatment effects, although additional work is absolutely needed. CBD, broadly speaking, has a complex pharmacology and the direct mechanism for its anti-convulsant effects are still being characterized. Currently, this mechanism appears to be independent of CB1 receptor activity (the primary cannabinoid receptor upon which CBD acts) and may relate to effects on intracellular calcium signaling via the orphan G protein-coupled receptor-55 (GPR55), transient receptor potential vanilloid-1 (TRPV1), and/or through modulation of adenosine-mediated signaling.

Were your results expected?

Based on prior observational work in other patient cohorts, we expected to observe general improvements; however, we were surprised at how marked the improvements were when analyzed in a longitudinal fashion. Specifically, we found that initiation of artisanal CBD product use was related to improved health outcomes over time, whereas patients who did not initiate product use did not see similar magnitude improvements. Though this work is observational and has limitations because of that, it does provide additional strength to the evidence of general health improvements observed with CBD initiation in this patient group.

You list possible reasons for the lack of difference in seizure control; which do you think is most important?

It is difficult to specify a single factor that may have resulted in the lack of difference in seizure control. One of the most important is that this was observational work, so there was no direct control over specific patient dosing of either CBD or other anticonvulsants. We also found that artisanal CBD users were less likely to report using traditional anticonvulsants than controls, suggesting that some of the lack of difference in seizure control may relate to reduction/substitution for traditional maintenance drugs. Additionally, many patients already experienced good seizure control at study onset making it more difficult to observe differences between groups (in other words, a floor effect). Future work using stringent experimental control is needed to further evaluate these findings and the impact of dosing frequency, amount, and chemotype on seizure control outcomes.

Did you observe any drawbacks? 

A small subset of patients did describe some negative experiences, but these were mainly minor. In fact, the most common complaint we recorded was that patients experienced difficulties in obtaining products because of price. It is important, however, that patients seek out guidance when planning to initiate these products to ensure optimal benefit for their health. Unfortunately, certain factors, such as stigma or lack of provider knowledge about medicinal cannabis, may lead to reduced patient-provider communication about CBD or other cannabinoid use. Lack of communication can heighten these possible risks when a treatment course is undertaken as entirely patient-directed rather guided by patient-provider interactions. 

Do you plan to continue this work in the future?

Yes, we’re continuing work in collaboration with the Realm of Caring Foundation to include ongoing observational work and planned experimental work. Recently, we launched a new version of the Observational Research Registry, which is an IRB-approved, online, survey-based study examining the health effects of medicinal cannabis use. It’s open to anyone in the world with internet access. We hope information from this study will help improve education efforts and add to the growing scientific understanding of the benefits and risks of cannabis/hemp use.

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About the Author

Phoebe Harkin

Deputy Editor

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