Managing ‘unrealistic expectations’ critical for CBD use in rheumatology
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DESTIN, Fla. — Managing expectations about efficacy is critical for patients with rheumatic diseases using cannabinoid products for pain, sleep or other complications, according to a presenter at the 2023 Congress of Clinical Rheumatology-East.
“There is some promise, but more data are needed,” Kevin P. Hill, MD, MHS, associate professor of psychiatry at Harvard Medical School, and director in the division of addiction psychiatry at Beth Israel Deaconess Medical Center, told attendees regarding the various CBD products that are available over the counter and online. “But there are some legitimate side effects that we should talk about.”
Although Hill stated that CBD can be used as “a buffer of sorts” for patients experiencing issues with pain, sleep, depression or anxiety, he made it clear that this should not be the first choice for clinicians.
“This is not a first-line treatment unless the patient has a prominent seizure disorder,” he said. “And it is better as an adjunct, not a monotherapy.”
Regarding the use of cannabinoids for pain, Hill stressed that the evidence is “mixed at best.”
That said, he added that many patients with rheumatic conditions have tried multiple medications for chronic or neuropathic pain, with little success.
“I am willing to have this conversation or try it as a last resort or a third-line medication,” Hill said. “From my experience, patients want some help. If they are doing it the right way, I am willing to talk to them.”
However, it is important to understand that despite widespread use, the evidence for CBD use in neuropathic pain has not improved.
Although most rheumatologists might be loath to prescribe patients a THC-containing medication, Hill suggested that the THC-containing dronabinol (Marinol, AbbVie) may have some clinical utility.
“THC with dronabinol is a helpful adjunct pain medication for some people,” he said.
Regardless of whether the patient is taking a CBD or THC product, Hill recommended close follow-up.
“Communication and documentation are critical,” he said. “There has to be open communication with doctor, patient, family and other providers who are treating this patient. You don’t want to be a passenger on the train.”
Another issue that is important to patients with rheumatic conditions is sleep.
“Sleep is one of the major things people use cannabinoids for,” Hill said. “The evidence just is not really there, at this point.”
The evidence is stronger for depression. However, swift and complete improvement is unlikely, according to Hill.
“Sometimes people have unrealistic expectations,” he said.
This pertains as much to efficacy as it does to safety. With FDA-approved medications, the adverse events are clearly explained on the label. For CBD products, those adverse events may be present, but because there are so few data, patients believe that they do not exist. Consequently, patients may experience unexpected complications that inhibit the perceived benefit of the intervention.
Dosing is also an issue.
“Dosing is a little bit more complicated than people believe, at this point,” Hill said. “A small amount of CBD in your coffee probably is not doing anything.”
Hill stated that he generally starts patients at 25 mg of CBD products for pain, sleep or other complaints.
“You are going to need to titrate into the hundreds of milligrams, potentially,” he said. “The high dose in some studies was over 1,000 mg per day. The point is you are going to need a lot of this, and that has ramifications in terms of side effects and cost.”
To that point, cost is a concern for many rheumatology patients, who commonly have to fight battles for prior authorization and insurance coverage. Hill stressed that the landscape is challenging even for clinicians who work in this space daily.
“I have never been able to get the FDA-approved version of CBD approved by an insurance company for an off-label indication,” Hill said. “Not once.”
This will force patients to pay for these products out of pocket.
“A lot of people are spending a lot of money on these products,” Hill said. “But the products are not doing as much as they hoped, and they get frustrated.”
Despite these hurdles, Hill acknowledged that patients across disease states and specialties continue to use CBD and THC products regularly.
“They are incredibly popular,” he said. “But there is still a lot we don’t know.”
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Hill K. The truth about CBD: Clinical uses and side effects. Presented at: Congress of Clinical Rheumatology-East annual symposium; May 4-7, 2023.
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