how much cbd oil should i take for epilepsy

Marijuana (Cannabis) and Epilepsy

The Virginia government “decriminalized” the cannabis derivative CBD (cannabidiol) and THC-A (a synthetic form of THC) in March, 2015. However, cannabis and its derivatives remain schedule 1 drugs regulated by the US Drug Enforcement Agency (DEA). Schedule 1 drugs are illegal by definition under federal law. So, it can’t technically be legal in Virginia, but only “decriminalized”. This brochure provides some information; you should talk to your epilepsy specialist for more information.

What is cannabis?

Cannabis is the plant name for marijuana. The main components of cannabis are tetrahydrocannabinol (THC) and cannabidiol (CBD). THC causes the “high” that is associated with smoking marijuana. CBD does not cause these effects. Most marijuana plants have little CBD and a lot of THC because they were grown for their psychoactive properties. However, some cannabis plants are high in CBD. CBD is most commonly available as an oil.

Why is CBD so popular recently?

A young girl with a severe type of epilepsy, called Dravet’s syndrome, was helped dramatically when her parents gave her CBD oil and this was reported in the popular press. At the same time, marijuana was being decriminalized in several states so CBD might become more available.

Is cannabis effective for treating epilepsy?

There are no large randomized controlled studies that show CBD is effective (or safe). There are some preliminary studies suggesting it might be effective for epilepsy. Many people have smoked marijuana in the past and many people now take CBD oil and think it helps their seizures. There are two older studies that suggested CBD reduces seizure frequency; one study had 9 patients in 1978 and the other study had 15 patients in 1980.

Will CBD make you high?

Probably not. In studies done so far, CBD does not cause euphoria, elation, happiness or feelings of being “high”.

What are the side effects of CBD?

The side effects have not been studied. It is popular to think that CBD must be harmless because so many people smoke marijuana “without any problems”. However, this is not correct. Studies of teenagers who smoked marijuana regularly had a lower IQ than those who didn’t and lost IQ points even when tested years after they stopped smoking marijuana. Also, we expect that the dose of CBD to control seizures will be much higher than the dose from recreational use of marijuana so it is not a fair comparison. Finally, the effects of CBD on brain development in young children are not known.

Is CBD legal in Virginia?

Since state laws cannot conflict with federal laws, and cannabis is illegal under federal law, cannabis can’t be legal in Virginia (or any other state) strictly speaking. However, Virginia has passed a law that it will not convict anyone who possesses CBD for the treatment of epilepsy. The law requires that the CBD be of the type that would be used for epilepsy, which means the concentration of CBD is at least 50 mg per ml but it must contain less than 5% THC. Most CBD oils advertised on the internet or in other venues do not contain this much CBD.

Is CBD available in Virginia?

CBD is not a drug and is not manufactured or regulated like a drug since it is not approved as safe and effective by the Food and Drug Administration (FDA). It can now be produced in Virginia without prosecution, similar to an herbal product. However, herbal products do not require any evidence that they are safe or effective and they do not have to follow “good manufacturing practice” which is required of pharmaceutical products. This type of compound is referred to as artisanal CBD oil. Since cannabis has not been legal until now, CBD is not currently available in Virginia even as artisanal CBD. A bigger problem is that artisanal CBD has an unknown amount of CBD and may contain impurities, such as pesticides. Some products sold as CBD oil have been found to not actually contain any CBD when examined by a laboratory. If someone were to take CBD oil, it would make sense to have it tested by a laboratory to determine the concentration of CBD and whether it has any impurities.

What is the procedure for getting CBD in Virginia?

The legislature has specified that physicians can complete a “Defendant’s Certificate” from the Virginia Board of Medicine that patients can carry with them. If a person is arrested for possession of CBD then they can produce this form for the Commonwealth’s Attorney and the judge will release them from the charges.

Is CBD recommended for treatment of epilepsy?

In general, artisanal CBD is not recommended by epilepsy experts because: 1) it is not known whether CBD is effective or safe, 2) there is no source of it in Virginia, 3) it is not available in a consistent concentration, and 4) it may contain unknown impurities. Overall, the risk to benefit ratio of CBD is not as good as for other normally available drugs for treatment of epilepsy. However, for people with epilepsy that persists despite the available therapy, then some people might accept the unknown risk and possible benefit of CBD. This should be done under the guidance of an epilepsy specialist who can consider this among other treatments.

Is there any ongoing research about CBD?

Yes. There are ongoing randomized controlled clinical trials of CBD for treatment of severe forms of epilepsy. It is likely that if the trials show a benefit for CBD and show it to be safe, then it could be approved by the FDA as a regular prescription drug in the next two or three years for the treatment of these severe epilepsies. If it is approved by the FDA, then epilepsy doctors could prescribe it like any other approved anti-seizure medication.

How hemp seed oil could offer new hope to epilepsy sufferers

The brain can build itself from saturated and monounsaturated fats but it has a preference for Omega 3 and 6 fatty acids. Research on humans and animals suggests that optimal brain health is achieved when linoleic acid (LA) and alpha linoleic acid (ALA) are consumed in a ratio of between 3.5:1 and 4:1—a ratio only naturally found in hemp.

The brain also has a requirement for cannabinoids, which regulate most of the major functions of the body including alertness, emotions, inflammation and cancer defences. The brain can make a small number of its own cannabinoids, but as 4,000 years of history and decades of scientific research indicate, it operates optimally when supplied with dietary cannabinoids, which can also only be found in hemp.

In many forms of epilepsy, damage to or faulty development of glucose receptors on brain cell membranes can starve brain cells of their preferred energy source. Going hand in hand with demand for glucose is oxygen delivery to brain cells. Depletion of either can result in a significant decrease in mental function.

Furthermore, essential fatty acid deficiency can lead to instability of brain cell membranes. This leaves the brain susceptible to damage and can cause aberrant electrical activity, resulting in seizures which in turn can cause further brain damage. This is a vicious circle of deficiency, dysfunction and deterioration.

A ketogenic diet is one in which a dietary emphasis on the medium chain triglycerides found in coconut oil leads to the production of ketones that can serve as an alternative energy source for brain cells. It has shown some limited success in improving function in metabolic conditions such as epilepsy, Alzheimer’s disease and Parkinson’s disease.

Can Medical Marijuana Control Seizures?

Yes, in some patients medical marijuana can control seizures.

Also called medical cannabis, it is derived from the whole cannabis plant or consists of chemicals in the plant and is used for medicinal purposes. Cannabinoids are substances in cannabis that act on cells in the body, including the brain. Two main ones are tetrahydrocannabinol (THC) and cannabidiol (CBD).

THC is the major chemical compound found in many strains of marijuana. When it binds to receptors in the brain, it creates the high that people feel, which is considered a psychoactive effect. CBD is not psychoactive and cannot create a high.

Epidiolex, a mostly purified plant-based cannabidiol oil, was approved by the US Food and Drug Administration (FDA) in 2018 to treat seizures in people with Dravet syndrome and Lennox-Gastaut syndrome, two rare forms of childhood-onset epilepsy. In 2020, Epidiolex was approved to treat seizures caused by tuberous sclerosis complex, a rare genetic disease that causes benign tumors to grow in the brain—which can lead to seizures—and other areas. The drug is a liquid that’s administered orally with a special syringe.

Approval of Epidiolex for Lennox-Gastaut and Dravet syndromes was based on four randomized, double-blind, placebo-controlled clinical trials of 516 patients. Taken with other antiseizure medications, Epidiolex significantly reduced the number of seizures compared with the placebo. In a clinical trial for people with seizures caused by tuberous sclerosis complex, Epidiolex reduced seizures by 48 percent, versus 24 percent for the placebo. Since its approval, the drug has helped many people with these types of seizures, but it is not effective for everyone and may need to be discontinued due to side effects such as liver problems and suicidal thoughts.

Researchers are not clear how CBD works to treat seizures, but they have a few theories: It may slow the sending of messages to the brain, change calcium levels in the brain that affect signals between cells, or reduce inflammation in the brain.

Marijuana products sold in dispensaries and online are not approved or regulated by the FDA and can vary significantly in quality. No government agency regularly tests such products for safety or effectiveness, or verifies that what is listed on the label is actually in the product. In some cases, commercial, nonprescription cannabis products are thought to increase seizures.

Researchers continue to investigate the different chemical compounds in marijuana and how they may help treat neurologic diseases, including other types of epilepsy. A meta-analysis published in Epilepsia in 2020 found that CBD improved the effect of clobazam (Onfi), a benzodiazepine used as an add-on treatment for seizures in both children and adults who have Lennox-Gastaut syndrome. A study published in Epilepsy & Behavior in 2018 showed that Epidiolex reduced seizures associated with four other types of epilepsy—CDKL5 deficiency disorder, Aicardi syndrome, Doose syndrome, and dup15q syndrome—from an average of 59 a month to 22 a month. The improvement lasted the entire 48 weeks of the study.

Side effects observed during the clinical trials of Epidiolex include fatigue, nausea, and diarrhea. Some patients experienced elevated liver enzymes, most likely because CBD is broken down in the liver. Because of that, patients need their liver enzymes monitored while taking Epidiolex or any other medical cannabis product.

In patients whose seizures are uncontrolled—which is the case for roughly 30 percent of people with epilepsy—an FDA-approved CBD product may be an appropriate treatment. That decision should be reached after a thorough evaluation at a specialized epilepsy center of the effectiveness of all other possible treatments (including FDA-approved new and add-on medicines, dietary therapy, devices, and surgery). If doctors prescribe Epidiolex, they must monitor patients’ enzyme levels and watch for any interactions with other medications.

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Dr. Patel is director of the Complex Epilepsy Clinic and associate medical director for quality improvement at Nationwide Children’s Hospital in Columbus, OH. He is also associate professor of clinical pediatrics and neurology at the Ohio State University College of Medicine.