Self-reported Cannabidiol (CBD) Use for Conditions With Proven Therapies

IMPORTANCE Use of cannabidiol (CBD) has markedly increased in the past 5 years, concurrent with marketing claims that over-the-counter CBD can be used to treat almost any health condition. However, the reasons why individuals use CBD remain unclear. OBJECTIVE To assess whether individuals are using CBD for diagnosable conditions that have evidence-based therapies. DESIGN, SETTING, AND PARTICIPANTS This case series assessed claimed treatment applications reportedbyCBDusersinpublictestimonialssharedontheRedditforumr/CBD.Ther/CBDforumwas selectedbecauseitincludesalarge,naturallyoccurringsampleof104917registeredindividualswho publicly discuss their experiences using CBD. All r/CBD posts were obtained from January 1, 2014, through August 31, 2019. A random sample of posts was drawn (n = 3000) and filtered to include posts in which self-identified CBD users testified why they take CBD (n = 376). EXPOSURES Self-reported use of CBD for medicinal purposes. MAIN OUTCOMES AND MEASURES Cannabidiol testimonials were divided into 11 subcategories corresponding with the condition’s medical subspecialty and 2 subcategories corresponding with wellness benefits. Posts were allowed to receive more than 1 label.


Introduction
Since 2014, the popularity of products containing the cannabis-derived chemical compound cannabidiol (CBD) has exponentially increased in all 50 US states. 1 This increase in popularity was concurrent with marketing claims that over-the-counter CBD can be used to treat almost any health condition, including acne, anxiety, and menstrual problems. 2At present, however, the only US Food and Drug Administration (FDA)-approved CBD-derived therapy is Epidiolex to treat Lennox-Gastaut syndrome and Dravet syndrome (2 rare forms of childhood epilepsy). 3Although other therapeutic applications of CBD have promise, 4 at present, use of CBD to treat other conditions is not recommended by the FDA. 5 Because of CBD marketing claims, the FDA has expressed concern by stating that "unsubstantiated therapeutic claims [are] a violation of the law [and] can put patients at risk." 3 However, the regulatory response of the FDA has been slow, with only a few warning letters issued 6 and no other major actions taken.In congressional testimony, the FDA commissioner stated the agency would take stronger and wider-ranging actions if patients with diagnosable conditions were using CBD as a substitute or adjunct for approved therapies. 7Delayed regulatory action may in part result from the lack of available data documenting the reasons why consumers are using CBD-containing products.
To fill this knowledge gap and inform regulatory decision-making, we analyzed testimonials posted on a social media website by self-identified CBD users as part of a case series study.Although the typical methods of assessing reasons for using a product are based on surveys with active users, no surveys of CBD use among US consumers currently exist, to our knowledge.Surveys can be costly and time-consuming to field and always require some formative data to inform their need and, if necessary, their questionnaire design. 8Large groups of CBD users are gathering on social media to openly discuss why they use CBD, including on Reddit, a social media website with 430 million monthly users that is divided into topically focused forums termed subreddits. 91][12] Herein, we sampled posts from the subreddit r/CBD in which registered individuals publicly discuss their experiences using CBD and thematically analyzed the content of their posts to identify self-reported CBD users as well as any treatment applications they describe.

Study Sample
For this case series, we obtained all r/CBD posts (N = 104 917) from January 1, 2014 (the inception of r/CBD), through August 31, 2019 (the last month with publicly available data at the time of analysis).
To identify use applications among CBD users, we randomly sampled 3000 original posts, with a mean of 78 words, to be further annotated.Comments were ignored because they are often nested in a stream of other comments and are typically briefer, thereby not including sufficient standalone details to be analyzed.The study was exempted from review and informed consent by the University of California, San Diego, Human Research Protections Program because the data were public and did not contain identifiable information (45 CFR §46).However, we edited direct quotations to avoid reverse identification. 13This study followed the reporting guideline for case series. 14o of us (E.C.L. and J.W.A.) developed a codebook for identifying posts authored by individuals who were providing testimonials about their personal CBD use.A post was considered a testimonial if the user was describing their own personal use of CBD (vs an anecdote about a friend) and their intended use application (vs dosing advice).With use of the codebook, each post was labeled by 2 of 4 total coders (including E.M.H. and R.T.).Coders disagreed on 2.7% of labels and resolved disagreements through unanimous deliberation.In total, 376 posts with a mean (SD) of 174 (175) words were labeled as testimonials.

JAMA Network Open | Public Health
Self-reported CBD Use for Conditions With Proven Therapies

Thematic Coding
Using open coding, 2 of us (E.C.L. and E.M.H.) reviewed the testimonials to develop a list of reasons for using CBD. 15There was no restriction on the number of labels for any post.Using axial coding, 4 of us (E.C.L., E.M.H., D.M.S., and J.W.A.) categorized the open codes into 2 major categories: (1)   testimonials of CBD as a treatment for diagnosable conditions or (2) testimonials of CBDs for wellness.The deciding factor was whether the user reported a self-or physician-diagnosed condition with the appropriate nomenclature as opposed to citing symptoms apart from a cited diagnosis.For example, "I take CBD…to treat my bipolar disorder," was labeled as a diagnosable condition and "CBD…makes me feel more focused" was labeled as a wellness application.
The same coders created subcategories that captured the specific intention within testimonials.
Testimonials of CBD use for wellness were divided into mental and physical wellness subcategories.
Testimonials of CBD use for treatment of diagnosable conditions were divided into 11 subcategories corresponding to medical subspecialties.For example, testimonials citing heart palpitations were combined into cardiological conditions.Although our thematic coding was subjective, all investigators agreed on the final definitions of the major categories (diagnosable conditions and wellness) and subcategories (Table 1).

Statistical Analysis
The monthly rates of posts to r/CBD and the percentage of testimonials with 95% CIs were calculated through bootstrapping using R, version 3.5.2(R Project for Statistical Computing).

Results
Posts to r/CBD increased from 1973 posts in 2016 to 6234 in 2017, 13 752 in 2018, and 11 602 during January through August 2019 (Figure).Using the random sample of r/CBD posts, we estimated that 12.1% (95% CI, 11.0%-13.4%) of all r/CBD posts were authored by individuals who provided testimonials of their use of CBD.Of the 376 posts labeled as testimonials, 90.0% (95% CI, 86.8%-92.8%) of testimonials included at least 1 claim that CBD could treat a diagnosable condition, whereas 29.5% (95% CI, 24.8%-34.2%)included at least 1 claim of a wellness benefit.Psychiatric conditions were the most commonly cited diagnosable condition, mentioned in 63.9% (95% CI, 59.0%-69.1%) of testimonials (Table 2), including "after using CBD for 2 months, my autism symptoms have improved."The second most commonly cited subcategory of diagnosable

Discussion
The public has increasingly taken to the social media platform Reddit to discuss CBD, with a increase in the rate of monthly posts that mirrors the increase and trajectory of popular interest in CBD. 1 A large fraction of these posts were authored by CBD users who described their own experience using CBD, and most of these testimonials cited taking CBD as a therapy for a diagnosable medical condition.
Although many potential therapeutic uses of CBD remain to be explored, our findings suggest that the public already perceives CBD as an effective therapeutic for many health conditions in ways that are potentially detrimental to public health. 5Because CBD is not an FDA-approved treatment for nearly all the conditions cited by users who post to Reddit, CBD users may unnecessarily experience prolonged illnesses that would otherwise be alleviated with proven effective treatments.
In addition, CBD use is not devoid of health risks, with known risks including liver damage and male reproductive toxic effects as well as potential drug interactions that may be associated with adverse events or diminished efficacy of approved therapies and additional unknown health risks. 5However, the pharmacology of CBD has not been well studied; thus, little is known about both the potential therapeutic benefits or the risks of short-or long-term use. 5e known and unknown risks of CBD use may be exacerbated by regulatory challenges that add context to our findings.For instance, products labeled as CBD often do not contain CBD or are mislabeled and sometimes contain psychoactive agents (eg, Δ9-tetrahydrocannabinol) not suitable for the treatments being sought by users. 16Moreover, CBD products may contain hazardous adulterants.For instance, nearly half of the hospitalized patients in the recent e-cigarette or vaping product use-associated lung injury outbreak vaped CBD-containing e-liquids, 17 and other mass poisonings have been linked to synthetic cannabinoids. 18In these events, there is currently no trackor-trace infrastructure in which batches can be sourced and removed from the CBD supply chain.
These dangers demand regulatory actions governing when, where, and how all CBD is sold, consistent with past sworn testimony by the FDA director. 7inicians could also play an important role in patient safety regarding CBD.Considering that some patients may use CBD for unexpected treatment applications (eg, heart palpitations), clinicians across specialties should inform patients that over-the-counter CBD is not an approved or recommended treatment and offer opportunities for patients to obtain efficacious treatments, as well as explain that CBD use may not be risk free.Such conversations could also provide an opportunity to identify unexplored conditions that could benefit from proven treatments.
Public health professionals should also provide accurate information.Substantial debate about erroneous health information has occurred, but few cases beyond vaccine refusal exist. 19,20Our findings suggest a need for accurate information about CBD.For instance, additional surveillance of

Limitations
Although this study provides a valuable look into how the general public is using CBD, it is unclear whether the results might generalize to the larger population because no external comparisons exist and information to weight the sample of Reddit users to align with population metrics was unavailable.In general, Reddit users tend to be younger and male, 22 but this may vary among subreddits in unknown ways.We could not document entire treatment regimens from the CBD testimonies (eg, prescribed medicines that CBD users might also be taking or replacing with CBD).
Because of the small sample, types of uses of CBD that are less prevalent were potentially undocumented and changes in use over time could not be explored.Automated approaches to content analyses (eg, topic models that allow for larger samples) could potentially overcome this limitation, but were not feasible for the present study because the concepts that we describe are complex and required a multistep approach that first identified testimonials and then the condition treated and its subcategories.After more is learned about how CBD and other products are discussed in social media posts or if text is generated in a more structured format, automated analyses could uncover additional clinically relevant ways that CBD is being used by the general public.Our estimates for diagnosable conditions may be significantly undercounted because some users described symptoms that may be associated with an unrevealed diagnosis (eg, an individual with depression taking CBD for sadness apart from mentioning their diagnosis).

Conclusions
The findings of this case series suggest that the public may already perceive CBD as an effective therapeutic for many health conditions.We believe this misperception warrants a multipronged response encompassing regulation, clinical practice, and health education.For example, regulators could enforce rules on market practices that may result in CBD being used to treat diagnosable conditions.Health care professionals could engage patients on their potential CBD use and redirect them to proven evidenced-based medicines.Public health agencies could run informational campaigns that encourage the public to seek treatment advice from health care professionals in lieu of CBD and provide vetted information on the limited proper uses of CBD for therapeutic benefit.

Table 1 .
Example Posts From the Reddit Forum r/CBD "I've seen mixed reviews about[PRODUCT].A local vendor that I trust and has good products started selling their stuff.After doing some research I saw that there were some bad experiences or reviews.I take CBD for ADHD and really like the clear-headedness aspect of it and also for depression.Letme know what you think of [PRODUCT] or any other [PRODUCT] you'd recommend especially if they clear your mind!" ߜ ߜ Psychiatric conditions, mental wellness Abbreviation: ADHD, attention-deficit/hyperactivity disorder; CBD, cannabidiol; NA, not applicable.a Each post was edited to omit content that might make the individual identifiable because the author may not have anticipated this content being publicly shared elsewhere and for length.JAMA Network Open | Public Health Self-reported CBD Use for Conditions With Proven Therapies JAMA Network Open.2020;3(10):e2020977. doi:10.1001/jamanetworkopen.2020.20977(Reprinted) October 15, 2020 3/8 Downloaded From: https://jamanetwork.com/ on 07/15/2022

Table 2 .
21eatment Testimonials for CBD as Reported by CBD Users on RedditCBD use that overcomes the limitations of this study seems warranted.Leaders could also begin curation campaigns, with experts participating in ongoing social media conversations and mass media campaigns providing evidenced-based CBD information.21 a Categories were developed through open-and axial-coding processes.Further details are given in the Methods section.b Each post was edited to omit content that might make the individual identifiable because the author may not have anticipated this content being publicly shared elsewhere and for length.JAMA Network Open.2020;3(10):e2020977. doi:10.1001/jamanetworkopen.2020.20977(Reprinted) October 15, 2020 5/8 Downloaded From: https://jamanetwork.com/ on 07/15/2022