Arthritis Foundation CBD Guidance for Adults with Arthritis
The Arthritis Foundation is aware of the growing popularity and availability of CBD-based products. Industry reports show that people with arthritis are among the top buyers, and pain is the leading reason for purchase. Our July 2019 survey of 2,600 people with arthritis shows significant use of and interest in CBD(cannabidiol).* Earlier surveys have shown repeatedly that pain is the most burdensome arthritis symptom.
The Arthritis Foundation Position
As the largest organization representing the voice and needs of people with arthritis, the Arthritis Foundation has always welcomed new treatment options because no single drug, supplement or therapy works for everyone. We believe patients should be empowered to find safe management strategies that are appropriate for them. The more options available, the likelier it is that more people will benefit.
We are intrigued by the potential of CBD to help people find pain relief and are on record urging the FDA to expedite the study and regulation of these products. While currently there is limited scientific evidence about CBD’s ability to help ease arthritis symptoms, and no universal quality standards or regulations exist, we have listened to our constituents and consulted with leading experts** to develop these general recommendations for adults who are interested in trying CBD.
- CBD may help with arthritis-related symptoms, such as pain, insomnia and anxiety, but there have been no rigorous clinical studies in people with arthritis to confirm this.
- While no major safety issues have been found with CBD when taken in moderate doses, potential drug interactions have been identified.
- CBD should never be used to replace disease-modifying drugs that help prevent permanent joint damage in inflammatory types of arthritis.
- CBD use should be discussed with your doctor in advance, with follow-up evaluations every three months or so, as would be done for any new treatment.
- There are no established clinical guidelines to inform usage. Experts recommend starting with a low dose, and if relief is inadequate, increase in small increments weekly.
- Buy from a reputable company that has each batch tested for purity, potency and safety by an independent laboratory and provides a certificate of analysis.
Frequently Asked Questions
The Basics: What Adults Should Know About CBD
What is CBD? CBD, short for cannabidiol, is an active compound found in the cannabis plant. CBD is not intoxicating but may cause some drowsiness. The CBD in most products is extracted from hemp, a variety of cannabis that has only traces (up to 0.3%) of THC, the active compound that gets people high.
Does CBD work for arthritis? Animal studies have suggested that CBD has pain-relieving and anti-inflammatory properties, but these effects have not been validated in quality studies in humans. Anecdotally, some people with arthritis who have tried CBD, but not all, report noticeable pain relief, sleep improvement and/or anxiety reduction.
Is CBD safe to use? Research evaluating the safety of CBD is underway. At this point very little is known. So far, no serious safety concerns have been associated with moderate doses. CBD is thought to have the potential to interact with some drugs commonly taken by people with arthritis. Talk to your doctor before trying CBD if you take any of the following: corticosteroids (such as prednisone), tofacitinib (Xeljanz), naproxen (Aleve), celecoxib (Celebrex), tramadol (Ultram), certain antidepressants, including amitriptyline (Elavil), citalopram (Celexa), fluoxetine (Prozac), mirtazapine (Remeron), paroxetine (Paxil), sertraline (Zoloft), and certain medications for fibromyalgia, including gabapentin (Neurontin) and pregabalin (Lyrica).
Are CBD products legal? CBD products derived from hemp are no longer considered Schedule I drugs under the federal Controlled Substances Act, but they still remain in a legal gray zone. There are changes underway on federal and state levels that will ultimately clarify the laws and regulations related to CBD-based products and sales. Despite that, they’re widely available in nearly every state and online. People who want to use CBD should check their state laws.
Taking the First Step
Should I give CBD a try? Without quality clinical studies on CBD and arthritis, doctors have not been able to say who might benefit from CBD, at what dose and in which form, who likely won’t benefit and who should avoid it. Still, there is agreement on several points:
- CBD is not a substitute for disease-modifying treatment for inflammatory arthritis.
- Patients who are interested in trying CBD should first talk to the health care provider who treats their arthritis before trying CBD. Together, they can review what has worked or not worked in the past, whether there are other options to try first, how to do a trial run, what to watch for and when to return for a follow-up visit to evaluate the results. Keep a symptom and dose diary to track effects.
- Quality CBD products can be expensive, especially when used for prolonged periods. To avoid wasting money, be completely sure that the product is truly having a positive effect on symptoms.
What type of product should I consider? CBD-based products can be taken orally, applied to the skin or inhaled. There are pros and cons for each.
By mouth. CBD that is swallowed, whether in capsules, food or liquid, is absorbed through the digestive tract. Absorption is slow and dosing is tricky due to the delayed onset of effect (one to two hours), unknown effects of stomach acids, recent meals and other factors.
Capsules can work for daily use after a safe, effective capsule dose has been established. Experts discourage taking CBD via edibles, like gummies and cookies, because dosing is unreliable, and they are appealing to children but do not come in childproof containers. Like any medicine, edibles should be secured out of sight and reach of children.
CBD can also be absorbed directly into the bloodstream by holding liquid from a spray or tincture (a liquid dosed by a dropper) under the tongue (sublingual) for 60 to 120 seconds. The taste may not be pleasant. Effects may be felt within 15 to 45 minutes.
On the skin. Topical products, like lotions and balms, are applied to the skin over a painful joint. Whether these products deliver CBD below the skin is unknown. Topical products may also include common over-the-counter ingredients such as menthol, capsaicin or camphor, making it difficult to determine if a positive effect is due to the CBD or another ingredient.
Inhaled. CBD can be inhaled via a vaporizing, or vape, pen. However, inhalation of vapor oils and chemical byproducts carry unknown risks, particularly for people with inflammatory arthritis. For this reason and because the Centers for Disease Control and Prevention is investigating vaping in association with widespread hospitalizations and deaths from severe pulmonary disease, vaping is not recommended.
How much CBD should I use? While there are no established clinical guidelines, the medical experts consulted by the Arthritis Foundation recommend the following for adults:
- When preparing to take a liquid form, be aware that the CBD extract is mixed with a carrier oil, so there are two measures to know: the amount of the liquid product to take (the dose) and the amount of CBD in each dose.
- Go low and slow. Start with just a few milligrams of CBD in sublingual form twice a day. If relief is inadequate after one week, increase the dose by that same amount. If needed, go up in small increments over several weeks. If you find relief, continue taking that dose twice daily to maintain a stable level of CBD in the blood.
- If CBD alone doesn’t work and you are in a state where medical or recreational marijuana is legal, talk to your doctor about taking CBD with a very low-dose THC product. Be aware that THC, even at low levels, may get you high, creating cognitive, motor and balance issues. Try THC-containing products at home or at night first, so you can sleep off any unwanted effects.
- After several weeks, if you don’t find relief with CBD alone or with a combination of CBD and very low THC, CBD may not be right for you.
- If you experience any unwanted side effects when using a CBD product, immediately discontinue use and inform your doctor.
What to look for when shopping? There is good reason to be a cautious shopper. CBD products are largely unregulated in the U.S. market. Independent testing has shown mislabeling and lack of quality control. The biggest issues are strength of CBD (significantly more or less than the label says), the presence of undeclared THC, and contamination with pesticides, metals and solvents.
- Look for products manufactured in the U.S. with ingredients grown domestically.
- Choose products made by companies that follow good manufacturing practices established by the FDA for pharmaceuticals or dietary supplements (a voluntary quality standard because CBD products are not federally regulated under either category) or required by the state where they are manufactured.
- Buy from companies that test each batch and provide a certificate of analysis from an independent lab that uses validated, standardized testing methods approved by the American Herbal Pharmacopoeia (AHP), the U.S. Pharmacopeia (USP) or the Association of Official Agricultural Chemists (AOAC).
- Avoid companies that claim their products have disease benefits.
- Be aware that marketers and people behind retail counters are not health professionals; they are salespeople. That’s why your doctor is your best source for guidance and monitoring when using an unregulated product.
*Read the survey results, “Patients Tell Us About CBD Use.”
**Our gratitude to the following experts for their guidance and review:
Kevin Boehnke, PhD, a researcher at the Chronic Pain and Fatigue Research Center at the University of Michigan, focuses on medical cannabis as an analgesic and opioid substitute in chronic pain.
Daniel Clauw, MD, a professor of anesthesiology, rheumatology and psychiatry at the University of Michigan and director of the Chronic Pain and Fatigue Research Center, leads research on arthritis pain and fibromyalgia, and the effects of cannabis, particularly CBD, in pain.
Mary Ann Fitzcharles, MD, an associate professor of medicine in the Division of Rheumatology at McGill University in Montreal, Quebec, conducts research on pain and rheumatic diseases. She is the lead author of the 2019 Canadian Rheumatology Association (CRA) position statement for medical cannabis.
To download and print the Arthritis Foundation CBD Guidance for Adults click here