A Case of Toxicity from Cannabidiol Gummy Ingestion This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, CBD oil is considered to have a very high safety profile, but like any substance with the ability to change brain chemistry, its use can have some side effects. Curious about how CBD affects the body? CBD has many promising uses. See how it may be able to help with your condition.
A Case of Toxicity from Cannabidiol Gummy Ingestion
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
A 56-year-old male with no known history of substance abuse and no known prior medical conditions presented via ambulance to the emergency department after being found by coworkers with bizarre behavior, vomiting, and slurred speech. He had legally purchased cannabidiol (CBD) gummies marketed for pain and anxiety relief at a gas station several hours prior. Vitals upon arrival were temperature 36.8 Celsius, heart rate (HR) 79, respiratory rate (RR) 12, blood pressure (BP) 113/60, and oxygen saturation (O2) of 84% on room air that improved upon arousal. Physical exam showed an obese man in no acute distress with a depressed level of consciousness but who awoke to painful stimuli. Neuro exam was significant for dysarthric, hypophonic speech. Labs were significant for a primary respiratory acidosis with concomitant mild lactic acid elevation, normal bicarbonate, and normal anion gap. A comprehensive urine toxicology screen including cannabis was negative. Vital signs three hours after presentation deteriorated, showing: HR 47, RR 8-12, BP 88/52, O2 78%. Electrocardiogram (EKG) revealed sinus bradycardia. The patient progressively became more obtunded and required constant stimuli in order to maintain a patent airway. Non-invasive positive pressure ventilation was not administered due to persistent emesis.
The patient underwent supportive care with intravenous fluids, oxygen, anti-emetics, continuous stimulation, and close neurologic monitoring with full recovery by the following morning. Further, patient history revealed that he had consumed two packages of CBD gummies, totaling 370 mg total of CBD (serving size on the package was 30 mg). He felt the products were healthy and safe based on packaging and therefore did not believe they would have any adverse effects.
CBD is one of many cannabinoids found in marijuana and marijuana-derived products. It is generally considered safe unlike its more psychoactive counterpart, tetrahydrocannabinol (THC), which has been linked to seizures, respiratory depression, and cardiovascular complications. CBD has surged in popularity recently, being marketed in oils, capsules, and candies as a health supplement, claiming to treat a wide variety of medical conditions such as glaucoma, pain, and even having beneficial effects on cancer prevention. Most currently available studies do not look at isolated CBD nor their synthetic equivalents, and purity is not guaranteed, thus leading to unforeseen side effects and toxicities. Moreover, these compounds do not show on traditional toxicology screens, posing a diagnostic dilemma for physicians. This case of respiratory depression and cardiovascular compromise in a relatively healthy man is just one example of the importance of considering synthetic CBD toxicity in the differential diagnosis, as there is little data available for recognizing and treating this condition.
Cannabidiol (CBD) is a rising trend in pop-culture. It can now be found in baked goods and candies, infused into coffees, and on the shelves of stores in cosmetics and oils. Benefits have been found for specific seizure disorders such as Lennox-Gastaut syndrome and Dravet syndrome; it is also being studied for its role in neuropathic pain [1-2]. The excitement over these treatments has spurred the production of a multitude of CBD-containing products that advertise a broad spectrum of clinical benefits such as improving arthritis-related pain, potential curative effects on cancers, to an overall improvement in well-being. While these claims are unfounded, the general consensus from the World Health Organization is that CBD is well-tolerated with a good safety profile . This is a case report of a 56-year-old male who experienced significant neurologic, cardiovascular, and respiratory depression due to CBD product intoxication.
A 56-year-old male on no medications with no known history of substance abuse presented via ambulance to the emergency department after being found by coworkers with bizarre behavior, vomiting, and slurred speech. He had legally purchased “CBD gummies” marketed for pain and anxiety relief three hours prior to his presenting to the emergency department, hoping they would help relieve pain from a recent back injury (Figures (Figures1, 1 , ,2 2 ).
Bag of CBD gummies consumed by patient marketed as a healthy solution for pain relief. Per packaging, each gummy contained 15 mg CBD.
A second bag of CBD Gummies consumed by the patient and scanned into the chart upon arrival. Product reportedly contained 50 mg CBD, 44 mg B12, and 400 IU D3 per gummy.
Upon arrival, vital signs (VS) were significant for hypoxia which did improve upon arousal. [Table [Table1 1 ]
|Initial Vital Signs|
|Temperature||36.8 degrees Celsius|
|Heart Rate||78 beats per minute|
|Respiratory Rate||12 breaths per minute|
|Oxygen Saturation||84% on room air|
Physical exam showed an obese male in no acute distress with a depressed level of consciousness, but who awoke to painful stimuli. Neuro exam was significant for dysarthric, hypophonic speech. He was also noted to have non-bilious, non-bloody emesis intermittently. Arterial blood gas at that time showed a mild acute respiratory acidosis with normal anion gap, normal bicarbonate, and a mild lactic acid elevation (Table (Table2 2 ).
|Arterial Blood Gas|
Labs were obtained and were notable for leukocytosis and mildly elevated creatinine kinase (CK) and CKMB (Table (Table3). 3 ). A comprehensive toxicology screen including cannabis was negative (Table (Table4 4 ).
WBC, white blood cell count; RBC, red blood cell count; Hb, hemoglobin; Hct: hematocrit; Na: sodium; K: potassium; Cl, chloride; CO2, bicarbonate; CK, creatinine kinase; CKMB, creatinine kinase-MB
(H) indicates an elevated level, (L) indicates a low level
|Initial Laboratory Values|
AMPX, amphetamines; BAR20: barbiturates; BEN, benzodiazepines; CAN 50, cannabinoids; OPI, opioids; PCP, phencyclidine; COC, cocaine; METH, methamphetamine
|Urine Drug Screen|
He was admitted to the medical floor, and VS 3 hours after presentation deteriorated, showing bradycardia with a nadir HR of 47, bradypnea as low as 8, blood pressure of 88/52 mmHg, and oxygen saturation as low as 78%. EKG revealed sinus bradycardia (Figure (Figure3). 3 ). Narcan was given multiple times without improvement. The patient progressively became more obtunded but was able to maintain a patent airway with intermittent, aggressive stimuli. He was transferred to the intensive care unit (ICU) for close monitoring and possible intubation. Non-invasive positive pressure ventilation was not administered due to continued emesis.
The patient underwent supportive care with intravenous fluids, anti-emetics, oxygen via nasal cannula, and continuous aggressive stimuli. The following day, 18 hours after admission, the patient was fully alert, oriented, and VS showed signs of improvement (Figures (Figures4 4 – -6). 6 ). The patient recalled consuming 2 entire packages of CBD gummies, totaling 370 mg of CBD (serving size on the package was 30mg). He felt the products were safe based on packaging and ate them as he would eat any other candy, not believing they would have any adverse effects.
Significant bradycardia observed at approximately 3 hours after initial presentation with spontaneous recovery at approximately 26 hours.
Patient became hypotensive almost immediately after presentation which remained persistent until spontaneous recovery began to be seen at approximately 17 hours post-presentation with full recovery seen by the 26-hour period.
Upon presentation, the patient demonstrated some bradypnea which became more pronounced and persistent in the 9-21 hours after initial presentation. Again, spontaneous recovery occurred at approximately the 26-hour mark.
This patient suffered neurologic and cardiopulmonary depression as a result of acute CBD intoxication. He was in his usual state of health prior to consuming two packs of CBD gummies. His heart rate, respiratory rate, and blood pressure dropped abruptly shortly after presentation and then experienced spontaneous recovery around 18-26 hours later without any intervention other than supportive care. This pattern of onset and recovery is consistent with toxin ingestion presumably from the CBD gummies which was the only known variable compared with the patient’s typical routine. Due to the report given by his coworkers, it was initially suspected that CBD overdose was the cause for this intoxication, of which there are no known published cases. However, given the lack of regulation and heterogeneity of over-the-counter CBD products, it is unclear which substance or substances were to blame in this patient. Similar cases are likely to be seen as these products become more commercially available.
One such case published in the literature is that of a 9-year-old boy with history of medically refractory epilepsy, diabetes insipidus, hypothyroidism, hemiplegic cerebral palsy, arachnoid cyst resection, and hypothalamic hamartoma resection who experienced profound neurologic and respiratory depression after CBD oil ingestion. The patient was being administered 1 drop of CBD oil to the gums daily but had incidental ingestion of 5 mL on the day of presentation. Upon arrival to the emergency department, he was noted to by hypothermic with depressed mental status and Glasgow coma score of 4-5 as well as decreased respiratory drive, leading to intubation. Urine screening was notable for a metabolite of THC, but testing was not readily available for CBD nor for synthetic cannabinoids. Mass spectrometry analysis of samples of the CBD oil from the same batch showed differing amounts of both CBD and THC. While the patient recovered, the exact constituent which caused the clinical findings mentioned was not able to be established due to lack of consistent formulations, purity, and potency of the commercially available products .
When comparing the two cases, there are certain similarities and differences which are worth mentioning. The pediatric patient consumed CBD oil, whereas the 56-year-old man ingested CBD gummies. In both scenarios, more of the CBD-labeled product was consumed than was recommended, and both patients required short-term hospitalization. In the case of the pediatric patient, testing for urine THC metabolites was also available. Neither patient had access to point-of-care testing for CBD or synthetic cannabinoids.
The CBD industry is projected to reach sales of $23 billion by 2023 . This surge is likely due to the excitement behind potentially new medical breakthroughs and the desire as a culture to shift towards therapies that are more “natural.” However, most products, such as the one purchased by this patient are unregulated. Products can contain varying amounts of CBD in addition to unstudied cannabinoids, THC, or toxins such as pesticides and heavy metals. A recent study found that only 31% of 84 CBD products sold online from 31 companies were labeled correctly regarding the concentration of CBD. Additionally, THC was found in 21% of samples among other cannabinoids .
With the lack of a known blood level at which CBD exhibits toxic effects and the possible contamination of the product with other cannabinoids and toxins, it is difficult to know whether this is a true CBD intoxication versus toxicity from one of the constituents found in the product. Contributing to this diagnostic dilemma is the fact that the majority of these products are synthetic which allows for a larger spectrum of cannabinoids and much higher concentrations than would be found in natural sources. Additionally, synthetic products do not appear on standard toxicology screening, as was the case in this patient  (Oral Presentation: Bass, DO, Jessica, Linz, MD, David. Hashing Out the Unknowns of the CBD Craze. 2019 SGIM Annual Meeting; 5/11/2019).
This is a case of profound neurologic, cardiac, and respiratory depression secondary to acute CBD product intoxication resulting in ICU admission. The patient’s lack of substance abuse history and unintentional overdose should raise concern for physicians as more people are consuming such products. The aggressive marketing of these products paired with the lack of regulation and quality control has the potential to cause a significant negative impact on public health. Clinicians should be aware of this when prompted for advice from patients as well as when treating patients with potential intoxication. Further research into these compounds is certainly indicated and regulation may be warranted for consumer protection.
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Are There Side Effects to CBD Oils, Pills, or Gummies?
The increasing prevalence of hemp-derived cannabidiol (CBD) products has necessitated the spread of information regarding its properties and — most importantly — whether it can be harmful. If you are brand new to the industry and looking to try something new, you are probably wondering: are there side effects to CBD oils, pills, or gummies? Thankfully, CBD is considered to have a very high safety profile, but like any substance with the ability to change brain chemistry, its use can result in potential side effects.
CBD is one of hundreds of compounds that are found in the cannabis plant, known as cannabinoids. These specialized molecules are designed to interact with specific internal receptors that are found throughout our brain and body. These cannabinoid receptors can influence many different processes regarding the modulation of other body systems, which is why people are affected when they consume cannabinoid compounds.
The Most common side effects of cbd
Those who are just learning about CBD may not realize that it does not have the ability to make you intoxicated. Tetrahydrocannabinol, or THC, is the only compound in cannabis that is capable of doing that. This is why hemp is ideal for extracting CBD oil, because it contains only trace amounts of THC, so users will not experience inebriation after its consumption.
However, several clinical trials have shown that patients who were treated with high doses of CBD (In some cases, over 1,300mg in a single day) had reported symptoms that ranged from mild to moderately severe, although nothing significantly life threatening. Research has so far indicated that the most common side effects of CBD can include things like queasiness, anxiety, fatigue, gastrointestinal issues, trouble with balance, dry mouth, and fluctuations in appetite or weight.
Nausea or vomiting
One reported side effect of CBD use is nausea, or vomiting. This can result from taking too high of a dose, which can be a different amount for each person as it is based on their individual biochemistry. For some new users, they may have trouble digesting the oil, which could potentially lead to an upset stomach.
When first trying out a CBD product, it is best to begin with the smallest dose possible, and work your way up. It is also important to note that when taking a tincture, it is necessary to hold the oil underneath your tongue for at least 1-2 minutes, or until the oil has been completely absorbed by the sublingual gland. In this way, the compounds are able to bypass the digestive system and go directly into the bloodstream.
Although many studies are currently underway to determine whether CBD helps with anxiety, some patients have indicated that it actually triggered rather than relieved their anxiety. This could be due to an overly high dose, although the quality of the CBD oil can have a huge effect as well. It may also correspond to the causes of individual stress or anxiety, whether they are due to external factors regarding lifestyle or internal body mechanisms that involve brain chemistry.
There has been a lot of research compiled regarding the use of CBD as a sleep aid, which makes sense as some users have reported excessive fatigue and tiredness associated with larger doses.
A small percentage of users experienced gastrointestinal issues like diarrhea after consuming CBD. This may also be due in part to the carrier oil that is used as a preservative in CBD products. Different types of carriers can include olive oil, coconut oil, avocado oil, or propylene glycol, and some people might be sensitive to a particular type.
Although there have been a few instances of dizziness associated with CBD use, this may also be an effect of gastrointestinal issues due to sensitivity of other ingredients. This is why it is very important to research all of the ingredients for a particular product, in case of allergies or other components that may cause a reaction.
Because CBD oil can be absorbed through the sublingual gland, cannabinoids have the potential to influence saliva production. However, if a CBD product causes excessive dry mouth, it may also be an indication of higher amounts of THC, which is primarily associated with this kind of symptom.
Always check the batch lab reports of a particular product to ensure that it does not have more than 0.3% THC. Some states have allowed for medical use of CBD products that contain more than the federal maximum amount of THC, so that is definitely something to consider and be aware of.
Changes in Appetite or Weight
Some consumers say they have experienced changes in their appetite or weight after using a CBD product. Cannabis products are often used in palliative care for terminal patients as a way to stimulate appetite, and this is considered one of the most common side effects of cannabinoids.
When cbd side effects may occur
It has become so popular in part because of its high safety profile, but when CBD side effects may occur can depend on the quality of the CBD product being consumed. Unfortunately, there are a lot of disreputable companies out there who are looking to make a quick buck in such a fast growing industry. This means they possibly use inferior processes for extracting the oil — some techniques involve the use of harsh chemicals which strip the plant of its natural components, and these processes could potentially leave behind trace amounts of toxic compounds. Currently, CO2 extraction is considered one of the cleanest and most efficient methods for extracting CBD oil.
It is important when choosing a CBD product to ensure that the company provides independent lab tests to confirm the purity of the oil, and to make sure that it does not contain higher amounts of THC, which is federally illegal. Many companies may not want to pay for this, which can be a disadvantage because not all batches of oil will come out with the same concentrations of cannabinoids, and it is important to follow these guidelines in order to ensure that only minimal amounts of THC are in the product.
Is CBD fda approved?
So, is CBD FDA approved? Currently, the Federal Drug Administration is still weighing in on CBD, and has not yet approved its medical use. Part of the issue is the expensive involved with clinical trials, which can cost millions of dollars.
There has been significant confusion within the industry because while hemp products and CBD are federally legal through the 2018 Farm Bill, the FDA has yet to approve their inclusion as an ingestible health supplement. However, FDA officials are aware of the high demand and pervasive use of CBD products, which has prompted them to request users, health practitioners, and industry experts to give their own experiences and comments regarding this issue. They held the first in a series of hearings in the summer of 2019, where people were invited to share their views, and they had also maintained a public comment forum on the FDA website where people were encouraged to give their thoughts on the matter.
It is believed that it will only be a matter of time before the FDA officially approves CBD, but many feel the process is taking too long. The fact that there are no established guidelines means that less scrupulous companies are able to operate with minimal oversight, which ultimately puts consumers at risk.
It is important to continue pressuring the FDA to make significant progress with regard to this decision, and hemp advocates continue to pursue legal avenues that would force them to speed up the process. Until then, both companies and customers will be at risk from the unstable regulatory landscape.
CBD: Benefits, Types, & Side Effects
CBD, or cannabidiol, is recommended for everything from anxiety and stress to indigestion and depression. And, a lot of people are using it. A recent Gallup poll found 1 in 7 adults in the U.S. has used CBD.
So, does it help? Studies of CBD are ongoing, but some benefits have been found.
What is CBD?
CBD is an herbal remedy – a treatment that comes from a plant, in this case, it is the cannabis sativa plant. Cannabis sativa has been used for thousands of years for both its healing and mind-altering effects.
There are two types of cannabis sativa: hemp and marijuana. The hemp plant is the source of CBD used in most products.
Hemp and marijuana plants
CBD is one of a group of substances called cannabinoids derived from the cannabis sativa plant.
There are dozens of cannabinoids, as well as other substances, in cannabis sativa.
CBD is the primary cannabinoid in hemp. It has various healing properties. For example, it seems to lessen inflammation, the body’s response to illness or injury. In this way, it may help treat many different diseases.
CBD is not psychoactive; it does not have a mind-altering effect.
CBD vs. THC
To better understand CBD, it helps to contrast it with tetrahydrocannabinol (THC). Many people are familiar with THC. It is the best known of the cannabinoids. THC was identified long before CBD. THC is the substance in marijuana that causes the high.
Marijuana contains more THC than CBD. Hemp has a very small amount of THC, less than 0.3 percent, and not enough to cause a high. As of 2018, CBD from hemp became legal in the U.S. with the Food and Drug Administration (FDA) maintaining control.
CBD’s main property is healing and it’s derived from the hemp plant. On the other hand, THC’s main property is mind-altering and it’s derived from the marijuana plant.
Excessive and continued use of CBD may lead to side effects, including memory loss, slow reaction time, and changes in mood such as irritability.
How CBD Works
As stated above, CBD is in a class of chemicals called cannabinoids. Because it comes from a plant, it is further classified as a phytocannabinoid.
The human body also produces natural cannabinoids, called endocannabinoids.
Both variations of cannabinoids act on cannabinoid receptors. These receptors are part of the complex endocannabinoid system (ECS). The system regulates the release of neurotransmitters (chemicals that communicate between nerve cells) in the brain, as well as in other parts of the nervous system. The ECS responds to both types of cannabinoids, phyto- and endo-.
By acting on the ECS, CBD may have many different effects on the body. Examples include: balancing the body’s overall physical functions (homeostasis), reducing pain sensation, and lessening the body’s reaction to injury or inflammation.
Medical Uses of CBD
CBD has been recommended for many different purposes, some of them tested, and some not. The prescription drug Epidiolex is the only CBD product approved by the FDA. It may be prescribed to treat two rare seizure disorders, or types of epilepsy, in children and adults.
Studies are ongoing, but some results show that CBD may be effective in reducing anxiety/stress and chronic (long-term) pain like back pain. It may also be effective for insomnia, or trouble sleeping.
There are studies of oral, topical, and inhaled CBD products for use in many other conditions, including dystonia (movement disorder), Fragile X syndrome (rare genetic disorder), graft-versus-host disease (bone marrow transplant rejection), multiple sclerosis (MS), opioid withdrawal, schizophrenia, and smoking cessation. CBD is also used to alleviate symptoms associated with Parkinson’s disease, but some study results advise against it.
Types of CBD Products
CBD products can be used by mouth (oral/edible) or applied to the skin (topical). These products have different concentrations of CBD.
CBD oil may be used both ways.
Other oral products include edible gummies and capsules. Topical CBD products may also be found in lotions, creams, or balms. Again, they are available in various concentrations.
The proper dosing of CBD for different conditions is still being studied, so new information is continuing to become available.
CBD should be used according to the manufacturer’s instructions. Make sure you read and follow the label carefully. Only use the amount instructed. Using more may increase the chance of side effects, interactions, or other problems.
The dose of a CBD product depends on the form and strength, as well as the concentration of CBD in it. It’s also based on whether or not it has other active ingredients.
Side Effects and Interactions of CBD
Common CBD side effects include: drowsiness, dry mouth, vomiting, decreased appetite, weight loss, and abnormal liver function blood tests.
INTERACTIONS: Check with your doctor or pharmacist before taking CBD with other medications. CBD may interact with some commonly prescribed medications including warfarin, lithium, sertraline, tramadol, codeine, captopril, and valproic acid and carbamazepine (both are anti-seizure medications).Fatty foods may increase the absorption of CBD.
CAUTIONS: People with liver problems or Parkinson’s disease should not take CBD.
Do not use CBD with medicines that are prescribed to control seizures or epilepsy (e.g. valproic acid or carbamazepine).
CBD may increase drowsiness when taken with other sedating medicines or herbal products.
Oral CBD for Pain
Research on the safety and effectiveness of oral CBD for pain is ongoing. Some of the research includes:
The National Academies of Sciences (NAS) found significant evidence that cannabis was an effective treatment for long-term (chronic) pain. However, much of the research was done outside of the U.S. And the forms of cannabis studied in the U.S. were not the same as those commonly used.
Reviews and meta-analyses of cannabinoids found the following:
Studies looked at the use of cannabinoids (THC alone and CBD combined with THC) in people with chronic pain. In general, results showed improvements in pain measures, but they were not statistically significant.
Studies found evidence, although not high-quality, that cannabis-based medicines reduced long-term nerve (chronic neuropathic) pain. All but two studies used plant-based THC/CBD mouth spray products (the other two used synthetic oral THC products).
Results of observational studies and randomized controlled trials (RCTs) of the effectiveness of cannabinoids in chronic non-cancer pain showed a 30% reduction in pain in 1 out of 3 of those using cannabinoids. These results were considered significant.
Topical CBD for Pain
There is also continuing research on the safety and effectiveness of topical CBD. Some of the research includes the following:
Although not in humans, an animal study found transdermal CBD had the ability to lessen the pain and inflammation of arthritis.
Topical cannabidiol oil was studied in 29 people with lower limb peripheral neuropathy. After using the oil for 4 weeks, results showed less intense and sharp pain and fewer other uncomfortable sensations.
Applications of transdermal cannabidiol were studied in people with temporomandibular (joint of the jaw) disorders (TMD) that caused myofascial (coverings of muscle) pain. Those studied had less muscle tension and pain after applying the topical CBD for 2 weeks.
Oral CBD to Help with Sleep
Oral CBD products may be used to help with sleep. This research includes the following:
Early results of research suggest that a 160mg dose of cannabidiol before bed significantly improves sleep duration compared to a placebo in patients with insomnia. Smaller doses did not have this effect. Also, patients did not feel drowsy the next morning.
Early research on CBD for the treatment of insomnia suggests that it may be effective. Additional studies are needed.
Animal studies of CBD found increased total sleep and improved sleep quality when sleep issues were associated with anxiety/stress.
Medical cannabis users reported they used cannabis with higher CBD and lower THC concentrations for their insomnia. They also reported a decrease in the time required to fall asleep.
A review and meta-analysis of 8 studies with low-quality evidence of cannabis-based medicines found that they were better at reducing sleep problems compared to inactive medicines (placebo).
A review of clinical trials of the effect of cannabinoids on sleep suggested that cannabinoids could improve sleep quality, decrease sleep disturbances, and decrease the time it takes to fall asleep. However, there were limiting factors, such as the small size of the studies.
An app was used to measure changes in insomnia in over 400 people taking medical cannabis. Results showed an average symptom severity reduction of 4.5 points on a 10-point scale, a significant improvement in insomnia.
Another review with meta-analysis of 104 studies evaluated cannabinoids for the treatment of chronic non-cancer pain. Within this review and analysis, the effect of cannabinoids on sleep was also examined. There was low-quality evidence of improved sleep.
The takeaway is that the initial research of CBD is promising but there is still much to learn. It may help with some conditions like long-term pain and sleep.
Because it is so widely available and recommended for so many problems, it must be used carefully and purchased from reliable sources.
CBD is just one of many supplements that can alleviate back pain or insomnia. Take a Goodpath assessment for an integrative program that incorporates supplements, nutrition, mind-body therapies, and exercise.