The Use of CBD in the U.S. Medical System

As CBD’s popularity grows, there are more questions around its use within the U.S. medical system. Can you get CBD products through your doctor? Do you need a prescription? How is it prescribed? What do the laws say? 

Can you get CBD products through your doctor? 

The short answer: Yes . . .

But the more correct answer: Yes—but it depends on your state’s laws, your doctor’s familiarity with the CBD products legalized within your state, and the conditions you’re seeking treatment for. 

Currently, there are four cannabinoid-based drugs approved by the U.S. Food and Drug Administration (FDA): Epidiolex, Marinol, Syndros, and Cesamet. Only one of those, Epidiolex, is specifically CBD, and it’s used to treat patients two years of age and older with severe forms of epilepsy, namely Dravet and Lennox-Gestaut syndromes. No matter where in the U.S. you live, for patients with those syndromes, you should be able to receive a prescription for Epidiolex if it aligns with your needs and treatment plan as set forth by your doctor. 

Beyond Epidiolex, it really depends, and specifically prescribing or recommending cannabis-derived CBD carries risks for hospitals and doctors. For hospitals in states where medical cannabis use is still illegal, they risk losing accreditation and federal funding and could incur heavy fines if they prescribe or recommend cannabis use for patients. Doctors face similar penalties. However, many hospitals, and especially those in states where cannabis-derived products are legal for medical and/or recreational use, have created cannabis policies to direct their use and their clinicians’ prescription or recommendation of cannabis-derived products, including CBD, for patients. Furthermore, some doctors have implemented a set of steps to minimize their liability around recommending CBD, including avoiding having any other perceived relationship with CBD or marijuana products or establishments, establishing a preexisting medical relationship with the patient, deciding together with the patient on treatment, and creating a treatment agreement.

Location and legal matters

As of the passing of the 2018 Farm Bill, CBD that is derived from hemp and contains less than 0.3% THC is technically legal to cultivate and sell across the country. For CBD products that fit under that umbrella, you don’t need a doctor’s prescription or recommendation. However, for CBD that doesn’t fit that bill—a.k.a. cannabis-derived CBD or that with greater than 0.3% THC—its availability, and your doctor’s ability to prescribe or recommend it to you, depends on where you live and what your state and local laws are surrounding cannabis products.

There are 33 states in which medical marijuana is legal. Eleven of those states have also legalized recreational marijuana. As of this year, 15 of the remaining states that have not legalized medical or recreational marijuana have passed explicit laws allowing the use of CBD extract with certain conditions. Some require a prescription by a licensed physician; some only allow CBD for use in treating specific conditions, like epilepsy, cancer, or ALS; some state it is only allowed for treating those conditions if the patient has not responded positively to other forms of treatment. 

Until recently, three states—Idaho, Nebraska, and South Dakota—still considered CBD in all forms illegal, with the exception of Epidiolex specifically prescribed for the treatment of severe epilepsy. However, in March 2020, South Dakota passed a hemp cultivation bill that will allow licensed producers to make industrial hemp products, including those that contain cannabidiol and no more than 0.3% of THC. The laws around the sale of those products remain unclear. In 2019, Nebraska also joined the bandwagon to allow the sale of CBD products beyond prescription-only Epidiolex, with the exception of food and beverage CBD products. However, the laws there are also still on the murky side, and it’s best to use caution. Of the most restrictive states, Idaho remains the lone holdout. Regarding cannabis-derived CBD, it must be completely free of THC and cannot be deemed “marijuana,” meaning it can only have been derived from specific parts of the cannabis plant: 

“Assuming cannabidiol does not contain any THC (which is more than the undersigned knows), in order to not be deemed ‘marijuana’ under Idaho Code §37-2701(t), it must be derived or produced from (a) mature stalks of the plant, (b) fiber produced from the stalks, (c) oil or cake made from the seeds or the achene of such plant, (d) any other compound, manufacture, salt, derivative, mixture, or preparation of the mature stalks, or (e) the sterilized seed of such plant which is incapable of germination.”

What doctors say

Some doctors will know more about and be more interested in CBD and its effects, potential and known, than others. Some groups of doctors have been keeping tabs on, or even using CBD with patients, for years and are full proponents of it. Others are newer the compound and still have many questions. Regardless of which side of the spectrum your doctor falls on, most will tell you that, clinically speaking, CBD has not been studied widely enough with enough human clinical trials to give definitive answers on its benefits as they pertain to specific conditions. As is the case with marijuana, the U.S. is admittedly behind many European countries in this regard. This is due to the fact that, on the federal level, cannabis is still considered a Schedule I substance, so funding and support for widespread research and clinical trials are very limited. 

But from what the science has shown thus far, doctors widely accept the benefits of CBD in treating epilepsy, with Epidiolex specifically. There is significant evidence of its anti-inflammatory properties (but some doctors still question its use in treating pain), as well as some promising evidence that it can help treat glioblastoma (brain tumors) and help alleviate the effects of chemotherapy, such as nausea, vomiting, and weight loss. Additionally, much evidence suggests its efficacy in helping to treat addiction. The research certainly points to potential benefits in CBD’s treatment of anxiety, however, as some doctors say, there is more hype than human-based research to back that at this point. Doctors are also prescribing CBD to help patients with insomnia, as it’s been shown to have potential efficacy in balancing sleep-wake cycles and reinstating natural sleep patterns. 

Doctors’ concerns

All this said, many doctors still have concerns and will err on the side of caution. First and foremost, as stated above, the science still needs to come further along before many doctors will feel comfortable prescribing it. 

Second, because the industry is still largely unregulated, doctors will tell you (as they should!) to only look for products that come from licensed, reputable manufacturers with third-party testing and certificates of analyses for all products. It’s imperative to know exactly what’s in the product and that it was made safely. 

Third, your doctor will need to consider drug interactions. CBD tends to inhibit the body’s cytochrome P450 system, which is affected by blood thinners. For patients on blood-thinning medication, doctors may be wary of prescribing CBD. 

And lastly, there are concerns around liver inflammation. While there has been no link between CBD and acute chemical hepatitis yet, in trials studying CBD’s treatment of childhood epilepsy, some children did experience a bump in liver enzymes, so doctors may steer patients with liver disease away from CBD products until the connection is studied with greater clarity.

Recommended forms of administration

In general, the most widely recommended form of administration of CBD products is oral, whether through capsules, gummies, or oil. If treating for pain and inflammation, topical products are recommended. Largely, the medical field warns of any administration that involves inhalation—smoking or vaping. Smoking in any fashion is widely considered unhealthy, and vaping has proven to cause additional safety concerns of its own, so most doctors will speak against those forms of administration and lead you to other administration methods. 

The laws around CBD and its use within our medical systems will continue to evolve, and they have to—CBD is here to stay. While the FDA has been slow to the punch thus far, with the increasing need for regulation and the recognition that people will continue to use CBD, the hope is that more federal direction comes out sooner than later, so people, science, and our medical systems can proceed.