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Statement from FDA Commissioner Scott Gottlieb, M.D., on new steps to advance agency’s continued evaluation of potential regulatory pathways for cannabis-containing and cannabis-derived products

For Immediate Release:
April 02, 2019
Statement From:

In recent years, we’ve seen a growing interest in the development of therapies and other FDA-regulated consumer products derived from cannabis (Cannabis sativa L.) and its components, including cannabidiol (CBD). This interest spans the range of product categories that the agency regulates. For example, we’ve seen, or heard of interest in, products containing cannabis or cannabis derivatives that are marketed as human drugs, dietary supplements, conventional foods, animal foods and drugs, and cosmetics, among other things. We also recognize that stakeholders are looking to the FDA for clarity on how our authorities apply to such products, what pathways are available to market such products lawfully under these authorities, and how the FDA is carrying out its responsibility to protect public health and safety with respect to such products.

Interest in these products increased last December when Congress passed the Agriculture Improvement Act of 2018 (the 2018 Farm Bill). Among other things, this law established a new category of cannabis classified as “hemp” – defined as cannabis and cannabis derivatives with extremely low (no more than 0.3 percent on a dry weight basis) concentrations of the psychoactive compound delta-9-tetrahydrocannabinol (THC). The 2018 Farm Bill removed hemp from the Controlled Substances Act, which means that it is no longer a controlled substance under federal law.

At the same time, Congress explicitly preserved the FDA’s current authority to regulate products containing cannabis or cannabis-derived compounds under the Federal Food, Drug, and Cosmetic Act (FD&C Act) and section 351 of the Public Health Service Act. In doing so, Congress recognized the agency’s important public health role with respect to all the products it regulates. This allows the FDA to continue enforcing the law to protect patients and the public while also providing potential regulatory pathways, to the extent permitted by law, for products containing cannabis and cannabis-derived compounds.

When the 2018 Farm Bill became law, I issued a statement explaining the FDA’s current approach to these products and our intended next steps. Consistent with the approach and commitments described in that statement, today the FDA is announcing a number of important new steps and actions to advance our consideration of a framework for the lawful marketing of appropriate cannabis and cannabis-derived products under our existing authorities. These new steps include:

  • A public hearing on May 31, as well as a broader opportunity for written public comment, for stakeholders to share their experiences and challenges with these products, including information and views related to product safety.
  • The formation of a high-level internal agency working group to explore potential pathways for dietary supplements and/or conventional foods containing CBD to be lawfully marketed; including a consideration of what statutory or regulatory changes might be needed and what the impact of such marketing would be on the public health.
  • Updates to our webpage with answers to frequently asked questions on this topic to help members of the public understand how the FDA’s requirements apply to these products.
  • The issuance of multiple warning letters to companies marketing CBD products with egregious and unfounded claims that are aimed at vulnerable populations.

Public Hearing

The public hearing will give stakeholders an opportunity to provide the FDA with additional input relevant to the agency’s regulatory strategy related to existing products, as well as the lawful pathways by which appropriate products containing cannabis or cannabis-derived compounds can be marketed, and how we can make these legal pathways more predictable and efficient. We hope to gain additional information and data for the FDA to consider with respect to products containing cannabis and cannabis-derived compounds, including CBD.

As we’ve stated before, we treat products containing cannabis or cannabis-derived compounds as we do any other FDA-regulated products. Among other things, the FDA requires a cannabis product (hemp-derived or otherwise) that’s marketed with a claim of therapeutic benefit to be approved by the FDA for its intended use before it may be introduced into interstate commerce. Additionally, it is unlawful to introduce food containing added CBD, or the psychoactive compound THC, into interstate commerce, or to market CBD or THC products as dietary supplements. This is because CBD and THC are active ingredients in FDA-approved drug products and were the subject of substantial clinical investigations before they were marketed as food. In such situations, with certain exceptions that are not applicable here, the only path that the FD&C Act allows for such substances to be added to foods or marketed as dietary supplements is if the FDA first issues a regulation, through notice-and-comment rulemaking, allowing such use.

While the availability of CBD products in particular has increased dramatically in recent years, open questions remain regarding the safety considerations raised by their widespread use. For example, during its review of the marketing application for Epidiolex– a purified form of CBD that the FDA approved in 2018 for use in the treatment of certain seizure disorders – the FDA identified certain safety risks, including the potential for liver injury. These are serious risks that can be managed when the product is taken under medical supervision in accordance with the FDA-approved labeling for the product, but it is less clear how this risk might be managed in a setting where this drug substance is used far more widely, without medical supervision and not in accordance with FDA-approved labeling. There are also unresolved questions regarding the cumulative exposure to CBD if people access it across a broad range of consumer products, as well as questions regarding the intended functionality of CBD in such products. Additionally, there are open questions about whether some threshold level of CBD could be allowed in foods without undermining the drug approval process or diminishing commercial incentives for further clinical study of the relevant drug substance.

It’s critical that we address these unanswered questions about CBD and other cannabis and cannabis-derived products to help inform the FDA’s regulatory oversight of these products – especially as the agency considers whether it could be appropriate to exercise its authority to allow the use of CBD in dietary supplements and other foods. As I stated in December, the FDA would only consider this path if the agency were able to determine that all other requirements in the FD&C Act are met, including those required for food additives or new dietary ingredients.

As part of the public hearing and related public comment period, the agency is interested in whether there are particular safety concerns that we should be aware of as we consider the FDA’s regulatory oversight and monitoring of these products. For example, we’re seeking comments, data and information on a variety of topics including: what levels of cannabis and cannabis-derived compounds cause safety concerns; how the mode of delivery (e.g., ingestion, absorption, inhalation) affects the safety of, and exposure to, these compounds; how cannabis and cannabis-derived compounds interact with other substances such as drug ingredients; and other questions outlined in the hearing announcement.

Additionally, we’re interested in how the incentives for, and the feasibility of, drug development with CBD and other cannabis-derived compounds would be affected if the commercial availability of products with these compounds, such as foods and dietary supplements, were to become significantly more widespread. We don’t want companies to forgo research that might support approval through the FDA’s drug review process, which could potentially lead to important safe and effective therapies. We also don’t want patients to forgo appropriate medical treatment by substituting unapproved products for approved medicines used to prevent, treat, mitigate or cure a particular disease or condition. For example, in the case of Epidiolex, the adequate and well-controlled clinical studies that supported its approval, and the assurance of manufacturing quality standards, can provide prescribers confidence in the drug’s uniform strength and consistent delivery that support appropriate dosing needed for treating patients with these complex and serious epilepsy syndromes. It’s important that we continue to assess whether there could be medical ramifications if patients choose to take CBD to treat certain diseases at levels higher or lower than studied in well-controlled clinical studies.

FDA Working Group

We hope that information we receive through the public hearing this May, as well as through the written public comment process, will help inform our consideration of these and other important scientific, technical and policy questions. Given the importance of these questions, and the significant public interest with respect to CBD in particular, we’re forming a high-level internal agency working group to explore potential pathways for dietary supplements and/or conventional foods containing CBD to be lawfully marketed. Given the importance of this issue, I’ve asked Principal Deputy Commissioner Amy Abernethy, M.D., Ph.D. and Principal Associate Commissioner for Policy Lowell Schiller, to co-chair the group and charged them with considering what options might be appropriate under our current authorities, in view of all the evidence before us and our agency’s fundamental public health mission. I’m also asking the group to consider whether there are legislative options that might lead to more efficient and appropriate pathways than might be available under current law – again, with the same science-based, public health focus that the FDA endeavors to bring to all matters before it. This is a complicated topic and we expect that it could take some time to resolve fully. Nevertheless, we're deeply focused on this issue and committed to continuing to engage relevant stakeholders as we consider potential paths forward. The working group plans to begin sharing information and/or findings with the public as early as Summer 2019.

New Compliance Actions

We’ll continue to use our authorities to take action against companies illegally selling these types of products when they are putting consumers at risk. I am deeply concerned about any circumstance where product developers make unproven claims to treat serious or life-threatening diseases, and where patients may be misled to forgo otherwise effective, available therapy and opt instead for a product that has no proven value or may cause them serious harm.

Today, the FDA is announcing that it has issued warning letters, in collaboration with the Federal Trade Commission, to three companies – Advanced Spine and Pain LLC (d/b/a Relievus), Nutra Pure LLC and PotNetwork Holdings Inc. – in response to their making unsubstantiated claims related to more than a dozen different products and spanning multiple product webpages, online stores and social media websites. The companies used these online platforms to make unfounded, egregious claims about their products' ability to limit, treat or cure cancer, neurodegenerative conditions, autoimmune diseases, opioid use disorder, and other serious diseases, without sufficient evidence and the legally required FDA approval. Examples of claims made by these companies include:

  • “CBD successfully stopped cancer cells in multiple different cervical cancer varieties.”
  • “CBD also decreased human glioma cell growth and invasion, thus suggesting a possible role of CBD as an antitumor agent.”
  • “For Alzheimer’s patients, CBD is one treatment option that is slowing the progression of that disease.”
  • “Fibromyalgia is conceived as a central sensitization state with secondary hyperalgesia. CBD has demonstrated the ability to block spinal, peripheral and gastrointestinal mechanisms responsible for the pain associated with migraines, fibromyalgia, IBS and other related disorders.”
  • “Cannabidiol May be Effective for Treating Substance Use Disorders.”
  • “CBD reduced the rewarding effects of morphine and reduced drug seeking of heroin.”
  • “CBD may be used to avoid or reduce withdrawal symptoms.”

I believe these are egregious, over-the-line claims and we won’t tolerate this kind of deceptive marketing to vulnerable patients. The FDA continues to be concerned about the proliferation of egregious medical claims being made about products asserting to contain CBD that haven’t been approved by the FDA, such as the products and companies receiving warning letters today. CBD is marketed in a variety of product types, such as oil drops, capsules, syrups, teas and topical lotions and creams. Often such products are sold online and are therefore available throughout the country.

Selling unapproved products with unsubstantiated therapeutic claims can put patients and consumers at risk. These products have not been shown to be safe or effective, and deceptive marketing of unproven treatments may keep some patients from accessing appropriate, recognized therapies to treat serious and even fatal diseases. Additionally, because they are not evaluated by the FDA, there may be other ingredients that are not disclosed, which may be harmful.

As our actions today make clear, the FDA stands ready to protect consumers from companies illegally selling CBD products that claim to prevent, diagnose, treat, or cure serious diseases, such as cancer, Alzheimer’s disease, psychiatric disorders and diabetes. The agency has and will continue to monitor the marketplace and take enforcement action as needed to protect the public health against companies illegally selling cannabis and cannabis-derived products that can put consumers at risk and are being marketed and distributed in violation of the FDA’s authorities.

Ultimately, we remain committed to exploring an appropriate, efficient and predictable regulatory framework to allow product developers that meet the requirements under our authorities to lawfully market these types of products. The actions we’re announcing today will allow us to continue to clarify our regulatory authority over these products and seek input from a broad range of stakeholders and examine a variety of approaches and considerations in the marketing and regulation of cannabis or cannabis-derived products, while continuing to protect the public’s health and safety.

The FDA, an agency within the U.S. Department of Health and Human Services, protects the public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation’s food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.

 

 

Cannabis For Parkinson's And Alzheimer's Diseases -An Interview With Dr. Ethan Russo

by Abbie Rosner

ETHAN RUSSO

Dr. Ethan Russo is a world-renowned authority on the medicinal use of cannabis; an academic researcher, author and industry leader whose expansive knowledge of cannabis therapeutics spans history, cultures and its myriad applications for improved health and wellbeing. A board-certified neurologist and former Senior Medical Advisor at GW Pharmaceutics, Dr. Russo is currently Director of Research and Development of the International Cannabis and Cannabinoids Institute, a consortium of international academic institutions and private companies dedicated to promoting medical cannabis research.

In this interview, Dr. Russo shares an informed and insightful vision of how cannabis-derived medicine stands to benefit two of the more intractable neurological conditions facing older adults, Parkinson’s (PD) and Alzheimer’s (AD) diseases.

Abbie Rosner: If medicinal cannabis targets our endocannabinoid system (ECS), what is the involvement of that system in PD and AD?

Dr. Ethan Russo: The ECS regulates most physiological systems in the body, but above all the nervous system, where it helps to achieve the balance that allows individual nerve cells to communicate. The ECS is disrupted in both AD and PD.

 

Rosner: What is the research with cannabinoids and Parkinson’s disease showing?

Russo: In a mouse model of PD, treatment with nabiximols (Sativex®), a cannabis- based pharmaceutical approved in 30 countries outside the USA, resulted in improvement in dopamine neurotransmitter function, and reduced oxidative stress (akin to “rust” of the nervous system), as well as leading to improvements in anxiety and self-injury behaviors.

Clinical results with treatment of PD with cannabis have been quite mixed. Cannabidiol (CBD) helped a few PD patients with psychotic symptoms, and some with a rapid-eye movement sleep disorder. Observational studies with smoked cannabis, presumably high in THC, reportedly produced acute benefits on tremor, rigidity and slow movement (bradykinesia). The best results in PD were reported in a Czech study in 2004, in which patients ate raw leaves of cannabis for as much as three months and reported significant improvement in overall function, tremor, bradykinesia and rigidity, with few side effects.

Rosner: And what about cannabis for AD?

Russo: The story in AD is even more intriguing. Both THC and CBD have been shown to interfere with the production of abnormal toxic matter in the brain of such patients. This is quite exciting, inasmuch as synthetic drugs designed for similar purposes have yet to advance in the clinic. Both THC and particularly CBD are known neuroprotective agents that hold the potential to slow or perhaps even halt the degenerative process. On the symptom side, THC as a single agent has proven beneficial in AD patients in reducing nocturnal agitation, improving sleep and appetite. Observations of nursing home patients in California with dementia have produced similar benefits as well as reducing the need for nursing intervention and amounts of other drugs.

There are four FDA-approved pharmaceuticals to treat memory loss in AD, but all have mild benefits on a temporary basis. These are designed to increase the amount of acetylcholine, the memory molecule in the brain that becomes depleted in AD. Interestingly, the terpenoid alpha-pinene is capable of boosting acetylcholine by inhibiting its breakdown, and with fewer side effects than the conventional drugs.

Rosner: We hear a lot of talk about THC and CBD, but what about the role of terpenes?

Russo: Terpenes are aromatic compounds from plants that are important in our everyday exposure to scents and flavors. Some of these, when combined with cannabinoids, boost their effects such that the result is greater than the sum of the parts. We discussed above the role of alpha-pinene to combat memory deficits in AD and PD. Linalool, a component of lavender essential oil as well as cannabis, has been demonstrated to calm agitation in AD. The terpene limonene, common to citrus and cannabis, is a powerful antidepressant and immune stimulator. Caryophyllene, a terpenoid with the distinction of also being a cannabinoid, is of key importance in AD, as it may help in clearance of beta-amyloid waste in the brain.

Rosner: CBD products are so popular now. But what price is paid when you remove THC from the cannabis equation?

Russo: A severe price may be paid if cannabis-based medicines are devoid of THC. It is clear from the above that THC has a major role to play in both symptomatic treatment of dementia and quite possibly in preventative benefit. The dangers of THC have been vastly exaggerated by alarmist politicians and the press, particularly in such contexts where alternatives have been extremely disappointing and are actually much more problematic. Very small doses of THC are required and their benefits outweigh any risks by healthy measures.

Rosner: You have also been a proponent of diet and other complementary approaches to cannabis.

Russo: Fascinating epidemiological studies have linked diet to degenerative diseases, especially AD. Diabetes and obesity, which are rampant in the USA, as well as trans-fats, all increase AD risk. In contrast, disease rates are lower in areas following a Mediterranean diet rich in monounsaturated olive oil and omega-3 fats from fish. We also know that daily cognitive challenges when carried into the elder years offer some protection, as does vigorous physical exercise.

An underappreciated factor in degenerative diseases is the microbiome, the bacterial content of the gut. We know that THC, rather than leading to obesity as one might surmise, rather changes the microbiome balance in the gut to favor bacteria that protect from development of obesity and the metabolic syndrome.

Great benefits may accrue to AD and PD patients through the use of probiotics (i.e., natural organic multi-culture yogurt, kefir, lacto-fermented vegetables, and supplements in capsules) and prebiotics (vegetable matter like acacia fiber, slippery elm, burdock root and supplement in capsules) that provide an optimum feedstock for the beneficial gut bacteria.

Rosner: From where we are today, what are the best approaches for prevention and treatment of PD and AD?

Russo: The best current approaches to AD and PD beyond what the conventional pharmacopoeia offers include: aerobic activity, daily mental exercise, Mediterranean diets with use of anti-inflammatory fruits and berries, probiotics and prebiotics. From cannabis, THC, THCA, CBD, beta-pinene, caryophyllene, linalool and limonene may all have important contributions to treatment of these disorders.

Rosner: Where do you see promise on the horizon?

Russo: While the current laboratory experiments have been extremely important in establishing a foundation for cannabis-based medicines in treatment of AD and PD, it is definitely time to move the effort into the clinical arena. It is clear that these conditions are increasing in our aging populations and conventional approaches to date have been less than satisfactory. Utilization of cannabis preparations with the right mixtures of cannabinoids and terpenoids show great promise to produce better results. While these may be simply palliative in reducing drug and care burdens, there is also the possibility of making a real difference in slowing or abrogating the pathological processes in these two disorders.

The conversation has been edited and condensed for clarity.