All about CBD for side effects, with Alex Capano, DNP, CRNP, FNP-BC

Legal restrictions on cannabis products have been loosened in recent years, attracting interest for their possibilities in relieving side effects from breast cancer treatment. Medical marijuana is the most well-known and controversial of these products, but cannabidiol, also known as CBD, has had the more dramatic rise in availability. CBD can be found legally nationwide in oils, tinctures, lotions, and even things like shampoos and lip balms, and claims to its health benefits have been as varied as the products themselves.

Living Beyond Breast Cancer CEO Jean Sachs, MSS, MLSP, spoke to Alex Capano, DNP, CRNP, FNP-BC, the chief science officer at Ecofibre Limited, a company that makes hemp-derived products such as CBD oil. Dr. Capano shares the basics about CBD: what it is, how it differs from medical marijuana, and why people use it. She also shares tips for wading through the many products marketed as using hemp to help you find something that will be helpful to you.

Managing side effects is a constant challenge, and we’re here to help you understand the science and safety of complementary and integrative therapies. For more on CBD, read Andrea Schmucki’s story about how she found pain relief by using CBD oils.

CBD resources recommended by Dr. Capano:

• Ongoing clinical trial looking at CBD’s effect on chemotherapy-induced peripheral neuropathy
• Americans for Safe Access
• Gossamer magazine
• Ananda Professional: maker of hemp products with professionals, such as Dr. Capano, available to answer questions

Alex Capano, DNP, CRNP, FNP-BC

Alex Capano, DNP, CRNP, FNP-BC, is the chief science officer at Ecofibre Limited, a global biotech company focused on hemp-derived supplements, food, textiles, and medical devices. She is also a senior fellow at Thomas Jefferson University and a board certified family nurse practitioner. Read more.

 

Jean A. Sachs, MSS, MLSP

Chief Executive Officer, Living Beyond Breast Cancer

Jean began her work with LBBC in 1996 when she became the organization’s first executive director; she was named CEO in 2008. Jean brings a lifetime of women’s advocacy experience to her role as CEO. She lives LBBC’s mission everyday by speaking with newly diagnosed women about their needs and gaps in support. Read more.

 

Jean Sachs (00:00):

Hi everyone. It's Jean Sachs. I'm the CEO of Living Beyond Breast Cancer. And first and foremost, I hope you're all doing well and staying safe today.

We are going to talk about CBD, a topic that I know there's a lot of interest in and we get a lot of questions on. People aren't exactly sure how to use it, where to buy it, what symptoms might it be most impactful for if you're able to try it. And I'm really pleased that we are being joined by someone who is a true expert on this topic. Dr. Alex Capano.

Hi, Alex. Nice to have you.

Alex is going to be able to answer a lot of questions about CBD, and she has a PhD in cannaboid science, which I didn't even know existed. She is the chief science officer at Ecofibre, and she's also a faculty member at the Lambert Center for the Study of Medicinal Cannabis and Hemp at Thomas Jefferson University, which is here in Philadelphia. Clearly she is the right person to be talking about this subject.

Welcome again. Why don't we just start by having you explain what is cannaboid science?

Alex Capano (01:19):

The word is cannabinoid — which no one knows, so I wouldn't expect anyone to get that right on their first try or first 10 tries — but cannabinoids are organic compounds that exist in plants. Typically, they exist most abundantly in what we consider a cannabis plant. A cannabis plant is differentiated into two buckets by our legal system. It's either considered hemp or it's considered what we call marijuana, and that's because of different cannabinoid content within those plants, but technically they're all cannabis. So hemp is part of the cannabis family. Cannabinoids are biologically active compounds that exist within the flowers of those plants and are used medicinally for a number of reasons. There's a ton of cannabinoids, but the two most abundant, most well researched, and most well used for therapeutic purposes are THC and CBD

Jean Sachs (02:30):

And is CBD and hemp, are those terms interchangeable?

Alex Capano (02:35):

No. Hemp is a cannabis plant that has, again, it's really a legal definition, so it's a cannabis plant that has 0.3 percent THC or less by weight when it's dried. And because of the way that THC and CBD exist in the plants, if you have low THC, you're able to get a lot of CBD out of that plant. Hemp is a really great source of CBD, but hemp is the plant and CBD is the compound that can be found in all cannabis plants, but is really abundant. Okay.

Jean Sachs (03:15):

THC is what we consider the marijuana side of the plant.

Alex Capano (03:20):

Well, that is the cannabinoid that is more abundant in what we call marijuana. That's a very charged word, so I always want to give a disclaimer when I use it, it's just really high THC. That is the compound that is responsible for intoxicating effects and is what people call psychoactive. Whereas CBD is not going to intoxicate and is not psychoactive, and both are used medicinally.

Jean Sachs (03:47):

Okay. It's amazing. I'm not going to try to pronounce the word, but I have to say learning about the plant is really interesting.

Let's talk about how CBD is used. I know it's comes in creams, it comes in liquid, it comes in chewables. If you could explain the difference and also give us a sense of what kinds of symptoms might it be helpful for, for those who are impacted by breast cancer?

Alex Capano (04:16):

I'll start by saying that there's a really big CBD bandwagon right now. It's in so many products, some of those are appropriate, and some of those, in my opinion, are a bit gimmicky, because someone won't get anything out of a CBD shampoo, for example, other than clean hair. It won't hurt you, but it’s not worth the extra cost.

Typically they're used effectively in what we call ingestibles. So that's usually an oil under the tongue. It can be a capsule or a soft gel. Gummies or chewables would also be in that category. That's for absorption systemically throughout the whole body. If you're doing it that way, sometimes it's just user preference, but if you use something like an oil under the tongue, it's going to bypass something called first-pass metabolism. It gets into your body faster, but the effects may not last as long and you get more bang for your buck, as far as bioavailability. If you have a capsule or a gummy or a chew tablet, that is going to have prolonged effects but it's a delayed onset and you lose a little bit of the active compounds to your gut metabolism.

Then topical application that could be cream, it could be a salve, really anything you could apply topically, that's a very appropriate method of delivery as well. You may get some full body absorption that way, but most of it's going to be local, so people use that for targeted areas. Again, there's a lot of other ways beyond that that CBD is available but not necessarily useful.

Jean Sachs (06:16)

Okay. So if you have, let's say neuropathy and your hands and feet, would that be better to use the more systemic liquid or a cream? And what about other symptoms?

Alex Capano (06:31):

I typically advise people to use a systemic delivery method for daily maintenance and ideally prevention of things like flare ups over time and use a topical as an adjunct for when things get worse or just if you enjoy it and you do think it feels better. It's getting at the source from two different directions.

So ideally oral, if you can tolerate it, you like it then certainly go with that full body route.

Topical is second line or a nice additive, but some people feel more comfortable trying topical at first, and I do think that that's often a really positive experience and then they become more comfortable with the products after that.

Jean Sachs (07:27)

Okay. And so what symptoms do you think it can be helpful for managing?

Alex Capano (07:30):

The most research that exists is around pain and that's all different modalities of pain, whether it's neuropathic pain, pain from an injury, or arthritis. We do have some really compelling evidence and there's been some nice systematic reviews — which are basically when researchers look at all of the different studies that are out there analyze them and come to a conclusion — that says, yes, these cannabinoids are effective for pain relief.

So pain would be number one and then numbers two and three that are close followers would be for sleep and symptoms that we would call anxiety or mood. So really pain, sleep, and mood. This is about quality of life, hopefully helping people to feel better and then hopefully live better, but this is not something that is going to treat the underlying disease of cancer or other diseases, for example. And I think there's unfortunately some bad actors who make those claims. It's really about symptoms associated with these chronic conditions.

Jean Sachs (08:50):

Okay. That's helpful. And if it's working and should you expect it to give you relief the first time, or is it something that’s more cumulative?

Alex Capano (09:02):

Well, ideally, you're sleeping better, you're less anxious, and you're not in pain or your pain is at least improved at some point on the pain scale.

It should help quickly, within two hours at most. And that's ingestible because it takes a little bit longer. Topical [application] works very quickly.

If you're using a good product, the tricky part is finding a dose that is appropriate for you, so I do tell people start low and go slow. So you may not be taking as much as you need to, if you don't feel anything at first, in that case, just add more, but you should feel relief pretty quickly.

Using regularly is going to enhance the effects because it's a very potent anti-inflammatory agent, so using that over time tends to compound the relief that it can provide.

Jean Sachs (10:04):

Yeah. That's actually really good to know that this is something that could just be part of your daily routine, not just when you have something acute.

Alex Capano (10:15):

Yes. Yeah. I think that that's really the most appropriate way to use it. And sometimes add more — if there's an issue and you feel that you need to and benefit from it fine — but I recommend daily use as part of it.

Jean Sachs (10:04):

So if someone is ready to go and actually purchase some CBD, how would you help them read the label and understand the difference between hemp oil, hemp extract, full spectrum, broad spectrum, and anything else you want to tell us?

Alex Capano (10:52):

Unfortunately, the industry right now is self-regulated. We don't have a regulatory body that's making sure everybody acts the right way. That really opens opportunity for people who aren't doing the right thing. There are plenty of companies that are [doing the right thing] and I think FDA will give guidance soon, but until they do, it's very self-regulated.

To be an informed consumer, it's important to look at the ingredients of the product. There's a lot of products out there that have hemp on the label or say hemp oil, or really hint that they have CBD in them, but what they have in them is hempseed oil. And that's nutritious and good for you and good for your skin, but it doesn't have any cannabinoids in it at all. So if you see hempseed oil or cannabis or sativa seed oil, and you don't see something like hemp extract or CBD on the actual ingredients, that doesn't have any cannabinoids in them.

I think that there's products that are intentionally misleading. So really look at the ingredient list — number one.

Hemp extract is typically what industry is using appropriately to say that these are cannabinoids derived from the hemp plant, and that’s also federally legal. People in all 50 States have access to them, you can travel with it, it's not going to intoxicate you and you're not going to get in any trouble with it. But there's a difference with hemp extracts, whether they are full spectrum or broad spectrum.

Full spectrum means it does include that small amount of THC that exists in hemp plants. It's not enough to intoxicate and it is federally legal, but we believe that small amount of THC enhances the therapeutic effects of the CBD and the other compounds. And there's pretty good scientific evidence to back that up.

Broad spectrum means that THC has been completely eliminated. Some people are really sensitive to even that tiny amount of THC, so that could be appropriate. Or if they're concerned about a drug test from their employer or something else, broad spectrum is a good option for them.

Jean Sachs (13:20):

That's really helpful. And what about price point? I've seen a real range.

Alex Capano (13:26):

It really depends on how potent the product is. You want to see how many milligrams of these active compounds, the cannabinoids — and really CBD is the powerhouse — are in the product.

If you're comparing, if you see two lotions for $30 and one has 150 milligrams and the other one has 300, you're getting a better deal with the 300 because that's really what you're paying for. Most CBD products are going to be between $25 and $60. Some of them go higher than that when they're much more concentrated or are larger, so they'll last longer that $25 to $60 range — typically that is about a month’s worth of use. So $1 to $2 a day.

Jean Sachs (14:29):

I see these everywhere, from pharmacies, supermarkets other kinds of retail stores. Should people be seeking out a specific place or an online resource? or is it really about reading the labels carefully?

Alex Capano (14:48):

I think that we'll get to a different place once regulation occurs, but for now it's being an informed consumer, trying to find trusted resources online. And that can be difficult because there's a lot of misinformation.

I think the best route for people, especially if they're trying to use this for therapeutic benefit is to go to a pharmacy. CBD is carried in some major chain pharmacies, but it was really adopted early by independent pharmacies, the mom and pop pharmacy shops. I did not really understand the level of service that you get at an independent pharmacy until I started working with the independent pharmacists on CBD.

That is a group that has really been early adopters. They tend to know more about this than most of the healthcare team. They often carry a range of products and can tell people, this is how you use it, this is how much you should take, and this is what I recommend, so that's a really good trusted resource that's going to be objective and cautious with somebody who's looking for this. Making that initial trip to a pharmacy is really the best bet.

Jean Sachs (16:20):

I know sometimes it's hard to find an independent pharmacist, but this is a good reason to look for one in your community. And I know that Ecofibre has some specific products that are sold in some of these pharmacies. Can you tell us a little bit about them?

Alex Capano (16:37):

We have a line called Ananda Professional that is only for pharmacies and practitioners. We do a lot of clinical education that is credentialed and very thorough. Folks can feel confident that, if they're buying that, the clinician who carries it has done a lot of research and a lot of learning and can help guide them. And also there's a lot of quality control and quality assurance. Again, this is not regulated. You want to make sure you're not wasting your money and getting what you pay for, certainly, but also that you're not putting anything in your body that you don't want to put in your body, there's no contaminants.

With that product, there's actually a QR code and you can scan it with your phone and it will bring up the lab reports of everything in that product. So you can feel not only confident that you're not being taken advantage of — frankly because that does happen with consumers — but also that you're putting something in your body that you feel OK.

Jean Sachs (16:20):

That's great to know. I know these products are also available at dispensaries where dispensaries are legal, which I now know is a fair number of States, but of course there is a cost to get the card, to be able to access the dispensary. Do you think it's important for people to do that if they're looking for CBD or are these other vendors just as good for CBD?

Alex Capano (18:18):

The other vendors are definitely just as good, and in some States they're arguably better. Some States that do have dispensaries, whether they're recreational or medicinal, have limitations with the products they can carry, and sometimes you can actually get better quality products, more variety, and better prices on CBD outside of the dispensary.

Jean Sachs (18:43):

That's helpful.

For our community, who's often actively in treatment for breast cancer, are you aware of any interactions with CBD that they should be concerned about? And should they let their oncologists know that they're going to add this to their daily routine? Is it important information?

Alex Capano (19:05):

Yes, I think so. Always inform your oncologist, of anything you're using that’s a supplement. It's tricky with CBD because it's metabolized through a pathway where so many medications are metabolized and many chemo agents that are commonly used in breast cancer are also metabolized through that pathway. So we get concerned about drug interactions, but what the evidence actually shows is that those drug interactions don't seem to actually occur or occur in any clinically significant way until someone uses a very, very high dose of CBD that we just don't see in these, over-the-counter hemp CBD products, or even those in dispensaries are just not that potent.

If you use 20 milligrams a day, the evidence shows that is about a hundred times less than the lowest risk of drug interactions.

That being said, we have a lot of research to do in my field. and you should definitely talk to your oncologist and hopefully they'll be up to speed or they'll get up to speed so they're able to answer your questions.

Jean Sachs (20:28):

Great. And are there some ongoing clinical trials looking at this that people could look up or maybe participate in?

Alex Capano (20:38):

Yes, actually we are partnering with a group of researchers and oncologists to look at chemotherapy, induced peripheral neuropathy in breast, ovarian, and colon cancer patients. And that will be using Ananda Professional full spectrum products.

These are over-the-counter in all 50 States, if that wasn't clear, so you don't need any of those cards, or even if you go to a pharmacy, you don't have to go behind the counter.

That [study] will certainly tell us, is this truly effective for improving neuropathic pain? But also we'll have a lot of data on safety, drug interactions, mood, and sleep changes, if there is any. I think oncologists and providers in general will begin to feel much more comfortable because there hasn't been a really rigorous clinical trial on that until now.

Jean Sachs (21:42):

Okay. And we'll make sure to link that information on the page.

I have two other questions. One is, if you are someone who really wants to try this and you want more information, but your healthcare provider just doesn't know a lot, are there places people can go to educate themselves that you think are reliable?

Alex Capano (22:05):

Yes, there's a group called Americans for Safe Access and they're a good resource. There's a publication that focuses on a number of different things, but it's called Gossamer. It's very editorial, but they really do their research, so they're a good resource.

Also at Ananda Professional, of course I am associated with them, but we are really the clinical leaders. And we do answer questions from patients and can ideally at least get you to someone locally who can really look closely. That's anandaprofessional.com and people can always reach out to us there.

Jean Sachs (22:54):

Great. And we'll link that on the site as well. Is there anything else you want to cover? Did we miss anything?

Alex Capano (23:02):

There's so much to say! No, I really think that for the time being it's important to go to a pharmacist or one of the websites I mentioned to try to get some unbiased information that is clinically sound.

And just try products again that are topical or ingestible. You don't need CBD in your mascara. I'm sure your eyes look great, but don't need the CBD for that, or in your shampoos. That can leave a bad taste in someone's mouth of, “I tried this and I just wasted my money.” So before spending, just take a little bit of time and I think you'll be happy that you did later.

Jean Sachs (23:51):

Thank you so much. It's so helpful to know that there are products out there that are safe and effective. And I know for the breast cancer community they're taking a lot of medication and they're really tearing down their immune system and having lots of side effects. So this is something that I think it's great for people to get educated about, and I hope everyone will take advantage of some of the resources that Dr. Capano shared. So thank you so much.

And I want to thank everyone for tuning in. Remember Living Beyond Breast Cancer has closed Facebook pages. So if you want to connect with other women log onto our website, we'll make sure we join you to them. And we will continue to create more resources on this topic. So be well, thank you.