Safety and Pharmacokinetics of Oral Cannabidiol When Administered Concomitantly with Intravenous Fentanyl Rajita Sinha, Phd, Didier Jutras-Aswad, MD, MS, Marilyn A

occurred at NS) between max = t P occurred at 3 and 1.5 hours in max t Volume 9, Number 3, May/June 2015 ), has received significant attention re- r 2015;9: 204–210) Cannabidiol does not exacerbate adverse effects asso- cannabidiol, cannabis, opioid dependence, pharmacoki- SAFTEE data were similar between groups without res- J Addict Med Recent research has also suggested CBD to have poten- Cannabis sativa annabidiol (CBD), a bioactive cannabinoid( in marijuana ¨ uller-Vahl & Emrich, 2008; Leweke et al., 2012; Englund J Addict Med ESEARCH cently regarding its potential medicinalbody properties. A of growing literaturediverse has disease reported processes including therapeutic(Mechoulam inflammation CBD et and effects cancer al., for 2013). 2007; Moreover, Massi CBD etproperties has al., (Fusar-Poli et been 2013; al., 2009; shown Mechaas Crippa therapeutic to et et potential al., al., have for 2011) psychosis asM anxiolytic (Borgwardt well et al., 2008; et al., 2013). Importantly, CBDnitive does performance not impair (Zuardi motor et orwhich al., cog- is 1982; important for Crippa medication et development. al., 2004), tial therapeutic effects for opioid abuseical on rat the studies basis that of demonstrated preclin- CBDof to heroin-seeking inhibit behavior reinstatement (Ren et al., 2009).effects Interestingly, the of CBD wererelapse observed behavior and to CBD continued beeven to specific 2 inhibit heroin to weeks seeking after cue-induced administration.also Other reported animal CBD studiesphine have to (Katsidoni et al., reduce 2013). These the preclinical studiesCBD suggest rewarding might be effects a of potentialcation treatment mor- of for novel opioid treatments abuse. for Identifi- opioid dependence is important C Results: piratory depression or cardiovascular complicationssession. during After any low-dose test CBD, sessions. Conclusions: ciated with intravenous fentanyl administration. CoadministrationCBD of and opioids was safe andfoundation well for tolerated. future These studies data examining provide CBD the asfor a opioid potential abuse. treatment Key Words: netics ( 3 and 4 hours in sessionsicant 1 differences and in 2, plasma respectively. CBD There were or no cortisol signif- (AUC sessions 1 and 2, respectively. After high-dose CBD, R ´ e g/kg μ in Humans RIGINAL O ), and area under the max t ˜ ao Paulo, Brazil; Chemistry and Drug Alex F.Manini, MD, MS, Georgia Yiannoulos, MS, Mateus M. Bergamaschi, PhD,

Cannabidiol (CBD) is hypothesized as a potential treat- ´ eal, and Department of Psychiatry, University of Montreal, 2015 American Society of Addiction Medicine This double-blind, placebo-controlled cross-over study of C ˜ ao Preto, University of S Copyright © 2015 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited.

Stephanie Hernandez, MD, MS, Ruben Olmedo, MD, Allan J. Barnes, BSc, Gary Winkel, PhD, Montreal, Canada. DA027781 (YLH) and CTSA (UL1RR029887). represent the ofﬁcial views of theNational National Institutes Institute of on Health. Drug Abuse or the School of [email protected]. at Mount Sinai, New York, NY 10029. E-mail: de Montr Metabolism (AJB, MAH), Intramuraltute Research on Drug Program, Abuse, National NIH, Baltimore, Insti- MD;ences Department (GW), of The Oncological Icahn Sci- School of MedicineDepartment at Mount of Sinai, Psychiatry New York,NY; (RS), Yale University SchoolHaven, CT; of and Medicine, Research New Center (DJA), Centre Hospitalier de l’Universit Emergency Medicine, TheNew Icahn York,NY; Departments School of Psychiatry of andThe Neuroscience Medicine Icahn (GY, YLH), at School ofMedical Mount Medicine Center, Sinai, Bronx, at NY; MountFood Department Sciences Sinai, of Analysis and Clinical, (MMB), JamesRibeir Toxicological School J and of Peters Pharmaceutical VA Sciences of

Safety and Pharmacokinetics of Oral Cannabidiol When Administered Concomitantly With Intravenous Fentanyl Rajita Sinha, PhD, Didier Jutras-Aswad, MD, MS, Marilyn A. Huestis, PhD, and Yasmin L. Hurd, PhD Received for publication October 2,Supported 2014; by accepted a January research 11, 2015. grant from theThis content National is solely Institutes the responsibility of of the Health authors grant and does not necessarily The authors declare no conﬂictsSend of interest. correspondence and reprint requests to Yasmin L. Hurd,Copyright PhD, Icahn ISSN: 1932-0620/15/0903-0204 DOI: 10.1097/ADM.0000000000000118 204 From the Division of Medical Toxicology (AFM, SH, RO), Department of (session 2) of intravenous fentanyl dose. The primary outcomeSystematic was Assessment the for Treatment Emergent Events (SAFTEE) to assess safety and adverse effects.time CBD to peak reach plasma peak concentrations, plasma concentrations ( ment for opioid addiction, withfor safety medication studies an development. important We determined ﬁrstmacokinetics step CBD when administered safety concomitantly and with phar- aopioid high-potency in healthy subjects. Methods: CBD, coadministered with intravenousthe fentanyl, Clinical Research was Center conducted in Mountmedical at center Sinai in Hospital, New a York City. Participants tertiary were healthy care aged volunteers 21 to 65route. Blood years samples with were obtained priorof before CBD opioid pretreatment, and followed by exposure, after a single 400 regardless 0.5 or (session of 1) 800 or 1.0 mg the Objectives: curve (AUC) were measured.

Downloaded from https://journals.lww.com/journaladdictionmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3XI41p+sDLxYskzzWJHpwFPA3MvB4/FX5gh6vcjyLLl1kCfZEXLPTKQ== on 08/15/2018 Downloaded from https://journals.lww.com/journaladdictionmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3XI41p+sDLxYskzzWJHpwFPA3MvB4/FX5gh6vcjyLLl1kCfZEXLPTKQ== on 08/15/2018 r J Addict Med Volume 9, Number 3, May/June 2015 Safety and Pharmacokinetics of Oral Cannabidiol because there are growing public health concerns regarding the tion, DSM-IV (SCID-IV) interview; history of cardiac disease, abuse, morbidity, and mortality from opioids. Opioid depen- arrhythmias, head trauma, seizures, or Axis I psychiatric con- dence is a chronic, relapsing medical disorder characterized by ditions under DSM-IV examined with the Mini-International drug craving, a persistent compulsion to use the drug with loss Neuropsychiatric Interview; hypersensitivity to any opioid or of control and profound drug-seeking behavior. The fact that cannabinoid; pregnant or breastfeeding; not using an appro- heroin relapses vulnerability is linked to cue-induced craving priate method of contraception; or intoxication at the time of response in opioid-dependent patients highlights the critical arrival on the site of the study or positive drug screen (screened need to develop therapeutic agents that diminish drug craving for cocaine, cannabis, opiates, benzodiazepines, barbiturates, in this population (Fatseas et al., 2011). phencyclidine, amphetamines). Subjects were compensated No specific data presently exist regarding CBD tolera- $150 per session and $10 for screening; compensation was bility and safety in regard to the interaction with opioids in determined on the basis of minimum wage, hours required humans, which is a critical first step for future clinical trials for study participation, and transportation fees. We enrolled to examine CBD’s potential as a therapy for opioid craving 6 subjects per study group similar to CBD studies using the and relapse in human abusers. As such, the objective of the same dose range in healthy subjects (Crippa et al., 2004). current study was to first determine the safety and pharmacokinetics of CBD when administered concomitantly with opioid Study Protocol in healthy human subjects. On the basis of previous investiga- During this 2-session, double-blind design, participants tions showing CBD to be safe (Zuardi et al., 1993, 2006; Crippa were administered placebo (group 1), 400 mg of oral CBD et al., 2004; Fusar-Poli et al., 2009), we hypothesized that CBD (group 2), or 800 mg of oral CBD (group 3) before both safety and pharmacokinetics would remain unchanged when 0.5 μg/kg (session 1) and 1.0 μg/kg (session 2) of IV fentanyl. coadministered at moderate doses (400-800 mg) with intra- Sessions were separated by at least 1 week to ensure a sufficient venous (IV) fentanyl. drug washout period. All participants were administered both doses of fentanyl with the low dose in the first session and the METHODS high dose in the second (Table 1). Study Design Fentanyl was coadministered with oral CBD in healthy Drugs human volunteers at the Clinical Research Center in Mount Cannabidiol, 99.9% pure CBD in corn oil, was encapsu- Sinai Hospital in New York City on the basis of the exper- lated in gelatin capsules and supplied by GW Pharmaceutical. imental design required by the Federal Drug Administration Placebo was corn oil in gelatin capsules identical to CBD and the Institutional Review Board at Mount Sinai as the first capsules. phase to subsequently examine CBD as a potential medication IV administration was selected because it is the route in opioid abusers. The design was a double-blind, placebo- of administration for many opioid users and minimizes in- controlled cross-over study. All volunteers signed a written terindividual variation in bioavailability noted with oral opi- informed consent document. A Data Safety and Monitoring oid administration (Glare & Walsh, 1991). Fentanyl was safely Board reviewed and approved the protocol before enrollment administered in this dose range in clinical settings and in pre- and reviewed all study data. vious studies conducted among healthy subjects and opioid- dependent subjects (Zacny et al., 1992). Participants Selection of 400 and 800 mg of CBD doses was based Healthy volunteers were recruited through advertise- on safety and toxicology data regarding CBD in humans and ment in the community and local newspapers and assigned animals, and also on previous CBD studies conducted in hu- a unique identification number. Inclusion criteria were past mans to assess other therapeutic properties. Our preliminary exposure at least once to an opioid (ie, codeine, morphine, and study showed a significant effect of CBD on heroin reinstate- fentanyl) and aged between 21 and 65 years. Exclusion criteria ment behavior at 5 mg/kg in rodents (Ren et al., 2009). In were using any psychoactive drug at any time during the study; humans, a similar CBD dose (300-400 mg) decreased corti- current diagnosis of drug dependence (except nicotine depen- sol (Zuardi et al., 1993), a biomarker related to stress, and dence) on the basis of Structured Clinical Interview for Diag- significantly altered cerebral blood flow in limbic and paral- nostic and Statistical Manual of Mental Disorders, Fourth Edi- imbic brain structures, such as the amygdala, that are highly

TABLE 1. A Blinded Randomized Experimental Design Assessed the Potential Safety of Oral CBD Administration Before Fentanyl Administration (N = 17)* Groups Session 1 (Wk 1): Fentanyl First Dose Session 2 (Wk 2): Fentanyl Second Dose Group 1: placebo CBD placebo + fentanyl dose 1 CBD placebo + fentanyl dose 2 Group 2: CBD 400 mg CBD 400 mg + fentanyl dose 1 CBD 400 mg + fentanyl dose 2 Group 3: CBD 800 mg CBD 800 mg + fentanyl dose 1 CBD 800 mg + fentanyl dose 2 *All participants received a low- (week 1) and high-dose (week 2) of fentanyl; fentanyl low and high doses were 0.5 and 1.0 μg/kg. Participants in group 1 received placebo, participants in group 2 received oral CBD 400 mg, and participants in group 3 received oral CBD 800 mg. The 2 sessions were separated with a 1-week interval to ensure sufﬁcient drug washout period. CBD, cannabidiol.

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Copyright © 2015 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited. r Manini et al. J Addict Med Volume 9, Number 3, May/June 2015 relevant to drug craving (Crippa et al., 2004). From a tolerabil- within 2 hours of collection. Plasma was separated and stored ity standpoint, 600 and 1280 mg of CBD has been administered in cryotubes at −80◦C. All samples were labeled with a unique to humans without toxicity or serious adverse events (Consroe barcode and study number for each subject, test session num- et al., 1991a; Zuardi et al., 1993, 2006, 2009; Borgwardt et al., ber, date, and time. Nine blood samples per session for cortisol 2008). testing (5 mL) were sent directly to the hospital laboratory for processing. Urine samples also were obtained to evaluate CBD Laboratory Session urinary excretion. Urine samples were collected in sterile mid- The timeline for blood sampling and outcome measures stream collection cups, stored at −80◦C. is summarized in Figure 1. Subjects were asked to fast for at least 8 hours before the session. Upon arrival at approximately Cannabidiol Assays 9 AM, subjects were administered a light, standardized break- Plasma CBD was quantified by 2-dimensional gas fast. Cannabidiol was administered 2 hours later. Another chromatography-mass spectrometry (GC-MS) as previ- standardized meal was administered 4 hours after CBD. Up ously described (Karschner et al., 2010). Briefly, 3 mL to 200 mL of water was allowed before capsule intake, but no of ice-cold acetonitrile was added to 1 mL of plasma alcohol or caffeine was allowed; subjects were not allowed to to precipitate proteins. After mixing, samples were cen- engage in intense physical activity. One hour before CBD, a trifuged and supernatant was added to preconditioned solid breathalyzer test was administered and a urine sample (rapid phase extraction columns (United Chemical Technologies, urine drug screen by immunoassay) was collected to ensure Styre Screen SSTHC06Z). Analytes of interest (CBD, that the subjects were not actively using alcohol or other THC, 11-OH-THC, THCCOOH) were eluted with 3 mL psychoactive substances (eg, cocaine, amphetamines, opioids, of hexane–ethyl acetate–acetic acid (49:49:2, v/v), and sedatives, cannabis, and hallucinogens). Blood samples (each dried under nitrogen. Samples were reconstituted with 10 mL) were obtained through an indwelling cannula from 25 μLofN,O-bis(trimethylsilyl)trifluoroacetamide with the forearm. We allowed a 1-hour delay before giving a single 1% trimethylchlorosilane and derivatized for 0.5 hours at 0.5- or 1.0-μg/kg IV fentanyl citrate dose. Because the time 70◦C. Samples were centrifuged and analyzed by electron to peak respiratory effects of IV fentanyl is approximately 5 ionization GC-MS. Limits of quantification were 0.125 to 15 minutes and peak CBD clinical effects were expected μg/L for 11-OH-THC, and 0.25 μg/mL for CBD, THC, to be 1 to 2 hours (Crippa et al., 2004), with peak plasma and THCCOOH. Upper limits of linearity were 25 μg/L for concentrations at approximately 3 hours (Agurell et al., CBD, and 100 μg/L for THC, 11-OH-THC, and THCCOOH. 1981), the delay between CBD and fentanyl administration Inter- and intra-assay imprecision (percent coefficient of ensured that CBD reached a significant plasma concentration variation [%CV]) was ≤6.4% and ≤7.8% for all analytes, before fentanyl possibly induced respiratory changes. The and quality control samples quantified within ±9.2% of target study timeline ensured that participants were under medical concentrations across the linear range. surveillance for the period during which expected adverse For urine, CBD was analyzed by GC-MS according to fentanyl effects would occur (up to 4 hours). a previously published method (Bergamaschi et al., 2013). Cannabidiol was linear from 2.5 to 500 μg/L. CBD intra- Sample Collection and Storage and inter-assay imprecision (%CV) was ≤3.2% and ≤3.4%, CBD blood samples were collected in 6-mL lithium hep- respectively. However, intra- and inter-assay bias (%CV) was arin vacutainers, centrifuged at 4◦C (3500 rpm for 10 minutes) ≤11.3%.

FIGURE 1. Experimental flowchart per study day for each subject. This flowchart outlines the session timeline to assess safety of CBD and fentanyl coadministration. Participants were provided a light meal 2 hours before CBD administration. Fentanyl was administered 60 minutes after administration of the CBD/placebo. A standard meal was provided 4 hours after CBD/placebo administration. Solid arrows indicate the time points when blood (10 mL) samples were collected. Vital signs, SAFTEE, VAS, PANAS, and OVAS were also assessed at the time indicated by the solid arrows except for the 3-hour time point (denoted by a star). Dashed arrows indicate times for urine collection (45 minutes and 2, 4, 6, and 8 hours). CBD indicates cannabidiol; OVAS, Opioid-Specific Visual Analog Scale; PANAS, Positive And Negative Affect Schedule; SAFTEE, Systematic Assessment For Treatment Emergent Events; VAS, Visual Analog Scale.

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Copyright © 2015 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited. r J Addict Med Volume 9, Number 3, May/June 2015 Safety and Pharmacokinetics of Oral Cannabidiol

Fentanyl Assay coadministration of CBD and fentanyl with fentanyl alone in Highly sensitive enzyme-linked immunosorbent assay terms of adverse events, physiological parameters variation, kits (Immunalysis Corporation, Pomona, California) were and pharmacokinetic properties. CBD pharmacokinetics and employed for fentanyl quantification from plasma samples. subjective measures were first analyzed for skew and kurtosis, Briefly, 20 μL of a diluted sample and 100-μL aliquot of en- and then analyzed for repeated measures analysis using either zyme conjugate (drug labeled with horseradish peroxidase) general or mixed linear models. Significance was set at 5% al- were added to 96 well microplates coated with fentanyl anti- pha and analyses were calculated by SPSS version 21 software bodies and incubated for 60 minutes. Assay limit of quantifi- (IBM, Chicago, Illinois). cation was 0.5 μg/L. RESULTS Primary Outcomes We assessed safety and adverse effects with the System- Baseline Characteristics atic Assessment for Treatment Emergent Events (SAFTEE) Seventeen subjects (n = 6 high-dose CBD group; n = (Levine & Schooler, 1986). The SAFTEE has 2 forms, a gen- 6 low-dose CBD group; n = 5 placebo group) were recruited, eral inquiry and a specific inquiry, which take approximately with mean age 38.5 (±2.2) years and 47% female and 53% 20 minutes to administer. The general inquiry is an open-ended white/47% black (no difference in age, sex, or race among inquiry about any physical or health problems and its impact on the 3 groups, P = NS). All subjects had a history of opioid functioning. The specific inquiry is a detailed and systematic exposure (the majority had received hydrocodone, oxycodone, inquiry regarding 78 adverse effects divided into 23 categories or codeine in association with postsurgical care) to minimize corresponding to organ systems or body parts (Watson et al., any potential negative opioid response and were prescreened 1988). to ensure absence of opioids via toxicology screens.

Secondary Outcomes and Subjective Measures Primary Safety Endpoint Peak plasma concentration (Cmax), time to peak plasma Each subject (n = 17) had 2 sessions (thus N = 34 concentration (tmax), and area under the curve (AUC) were sessions), each of which was analyzed independently. There calculated from CBD plasma concentrations. Urine sampling were no serious adverse events such as respiratory depression allowed estimation of clearance, calculated as a percentage of or cardiovascular compromise in any subject. Minor adverse dose excreted over 8 hours. Cortisol plasma levels and AUC events reported by subjects during (and immediately after) ses- differences between groups were also examined. Plasma con- sions were recorded as dichotomous variables (in descending centration and urine AUC were calculated by the following number of occurrences): dizziness/drowsiness (n = 5), itch- n + = = equation: AUC = C1 C2 × (t − t ), where C is concen- ingorrash(n 3), headache (n 2), abdominal discomfort 2 2 1 1 = = = t=0 (n 2), nausea/vomiting (n 2), and diarrhea (n 2). There tration at time 1 (t1) and C2 is concentration at time 2 (t2). were no significant associations between CBD Cmax (peak of Interaction between fentanyl dose and both (i) plasma CBD maximum concentration) and occurrence of adverse events concentrations and (ii) urinary CBD clearance was assessed (t test P = NS). The 2 episodes of vomiting occurred in subjects using mixed linear models. with significantly lower CBD Cmax (t test P < 0.05). One sub- Anxiety was assessed with a Visual Analog Scale (VAS). ject developed itching and a rash that resolved after treatment The Positive and Negative Affect Schedule (PANAS) recorded with diphenhydramine. SAFTEE results are summarized in positive and negative affect subscores as previously described Table 2. (Watson et al., 1988). The Specific Opiate VAS (OVAS) Clinical monitoring of vital signs (temperature, heart was administered to assess potential variations in fentanyl rate, respiratory rate, blood pressure, oxygen saturation) was subjective effects. All scales were administered in less than performed continuously and was analyzed at time points 10 minutes. Vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation, and body temperature), respiratory func- TABLE 2. Systematic Assessment for Treatment Emergent tion (inspired and expired oxygen and carbon dioxide concen- Events Data* trations, arterial hemoglobin–oxygen saturation, and respira- Fentanyl Session Group 1 Group 2 Group 3 tory rate) and electrocardiogram were continuously monitored throughout the session. Vital signs were recorded as in Figure Session 1 Itching Dizzy (n = 2) Blurry vision Drowsy Drowsy (n = 2) Diarrhea† 1. Patients were monitored for respiratory depression (defined Bruxism Headache as a diminished oxygen saturation below 90% or a respiratory Session 2 Itching Drowsy (n = 3) Abdominal pain rate <12) and cardiovascular compromise (defined as abnor- (n = 2)† mal heart rate or blood pressure outside of standard normal Nausea Anxiety Diaphoresis parameters) during the study. Dizzy Dizzy Dizzy Dry mouth Nausea Diarrhea† Vomit Itching Statistical Analysis Vomit† Continuous variables were summarized with means ± *Fentanyl dosing: session 1 = 0.5 μg/kg, session 2 = 1.0 μg/kg; CBD dosing: standard errors. The t test, Kruskal-Wallis, and analysis of vari- low = 400 mg, high = 800 mg. ance (ANOVA) (post-hoc testing with Tukey test) compared †The same individual.

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Copyright © 2015 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited. r Manini et al. J Addict Med Volume 9, Number 3, May/June 2015 according to Figure 1 using AUC between groups. There were no occurrences of respiratory depression (<12 breaths/min) or cardiovascular compromise (mean arterial pressure <60 mm Hg, heart rate >100) in any subject at any time point. Higher fentanyl dose (1.0 μg/kg vs 0.5 μg/kg) was associated with slightly lower respiratory rate and temperature (mean AUC t test P < 0.05); however, cardiovascular parameters were similar between sessions (P = NS).CBDdose(0mgvs 400 mg vs 800 mg) was not associated with any significant differences in vital sign parameters throughout the study (mean AUC ANOVA P = NS for all). Plasma CBD Concentrations Plasma CBD concentrations were measured at baseline and at selected time points according to the protocol outlined in Figure 1. Group 1 (placebo) measurements served as the negative control. In group 2 (400 mg of CBD), time to peak plasma concentrations (tmax) occurred at 3 hours (mean Cmax 181.2 ± 39.8 μg/L) and 1.5 hours (Cmax 114.2 ± 19.5 μg/L) in sessions 1 (0.5 μg/kg of fentanyl) and 2 (1.0 μg/kg of fentanyl), respectively (Fig. 2A). In group 3 (800 mg of CBD), tmax occurred at 3 hours (mean Cmax 221.1 ± 35.6 μg/L) and 4 hours (mean Cmax 157.1 ± 49.0 μg/L) in sessions 1 and 2, respectively (Fig. 2B). In group 2, AUCs (μg·hr/dL) for sessions 1 and 2 were 704 ± 283 and 482 ± 314, whereas group 3 with the highest CBD dose tested had AUCs of 867 ± 304 and 722 ± 443, respectively (F[2,14] = 55.34; P < 0.0001). There was no significant interaction between plasma CBD concentrations across fentanyl sessions as demonstrated in Figure 2C (mixed linear model P = NS); 800 mg of CBD tended to have higher plasma concentrations irrespective of the fentanyl dose. Urinary CBD Excretion Urinary excretion of unchanged CBD (<5% total) and CBD conjugates (metabolite, majority of excretion) were measured in subjects’ urine at time points according to the protocol outlined in Figure 1. After the low-dose CBD, mean peak uri- FIGURE 2. Plasma CBD concentrations. Mean (±SEM) plasma nary concentrations (Umax) of CBD conjugates occurred at = μ = μ CBD concentrations across time (in hours) were not sig- 6 hours (Umax 4.6 g/L) and 2 hours (Umax 2.9 g/L) in nificantly affected by fentanyl dose (AUC Wilcoxon P = sessions 1 and 2, respectively. In the high-dose CBD group, NS). Mean (±SEM) plasma CBD concentrations for low-dose mean peak urinary concentrations of CBD conjugates occurred (400 mg) CBD (A) and high-dose (800 mg) CBD (B). The at 4 hours (Umax = 3.7 μg/L) and 6 hours (Umax = 2.8 μg/L) combined curves (C) for all groups (0, 400, and 800 mg of in sessions 1 and 2, respectively. Higher fentanyl dose in ses- CBD) across the 2 fentanyl sessions. CBD indicates cannabidiol; sion 2 was associated with significantly decreased mean CBD NS, not significant; SEM, standard error of the mean. *Signifi- clearance (F[2,12] = 5.42; P = 0.02). cant difference between groups at one given time point (t test P < 0.5). Plasma Fentanyl Concentrations None of the subjects in either the placebo or CBD groups showed detectable plasma fentanyl concentrations.

Plasma Cortisol 23.9 and 69.3 ± 40.4, respectively. There were no signiﬁcant Each subject had plasma cortisol concentrations (μg/dL) between-group or within-group correlations between cortisol analyzed at each time point and AUC (μg*h/dL) calculated concentration AUCs using ANOVA (P = NS), or when ana- over 8 hours. Mean plasma cortisol concentrations in group 1 lyzed by CBD dose at any study time point (Pearson r ranged (placebo) in sessions 1 and 2 were 46.9 ± 12.7 and 56.3 ± 20.9, from −0.134 to +0.21; P = NS for all). When plasma corti- respectively. Mean plasma cortisol concentrations in group 2 sol concentrations from all study time points were combined, (low-dose CBD) in sessions 1 and 2 were 55.9 ± 24.1 and 69.7 there was no correlation between CBD dose and cortisol (r = ± 27.2, respectively, and in group 3 (high-dose CBD) 46.2 ± 0.065; P = NS).

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Table 3. Subjective Measures Analysis by Treatment Group* studied than THC. It was previously demonstrated that CBD did not affect brain morphine and methadone concentrations PANAS in mice (Reid & Bornheim, 2001). However, it was suggested † Treatment Group Positive Negative OVAS that that although CBD has weak activity at CB1 and CB2 CBD 0 mg—0.5 fentanyl 33.56 10.04 19.17 receptors, it may act as an inverse agonist at these receptors CBD 0 mg—1.0 fentanyl 31.50 10.04 19.61 (Pertwee et al., 2002; Thomas et al., 2007). In addition, CBD CBD 400 mg—0.5 fentanyl 23.81 10.08 18.44 stimulates the transient receptor potential V2 (TRPV2) pro- CBD 400 mg—1.0 fentanyl 23.10 10.25 17.52 tein (Qin et al., 2008), also known as vanilloid receptor-like 1 CBD 800 mg—0.5 fentanyl 33.85 10.81 24.56 CBD 800 mg—1.0 fentanyl 33.06 10.40 23.92 (VRL-1), a member of the TRP superfamily of nonselective, ligand-gated cation channels that seem to serve as the so- *Mean scores for the subjective measures (PANAS, OVAS) and the results of the repeated measures statistical analysis. called ionotropic cannabinoid receptors. Cannabidiol was also †Mixed linear model with repeated measures. reported to alter the hydrolysis and cellular uptake of the endo- CBD, cannabidiol; OVAS, Opiate Visual Analog Scales; PANAS, Positive and Neg- cannabinoid anandamide (Bisogno et al., 2001). Cannabidiol ative Affect Schedule. modulates allosterically μ- and δ-opioid receptors, but only at high concentrations (Kathmann et al., 2006). μ-Opioid recep- Subjective Measures tors are colocalized with type 1 cannabinoid receptor (CB1) The anxiety VAS, PANAS (positive and negative sub- in striatal output projection neurons of the nucleus accumbens scores), and OVAS were administered across 8 time points for and dorsal striatum that modulates reward, goal-directed be- each session as per Figure 1. There were no significant main havior, and habit formation relevant to addiction (Rodriguez effects for CBD for any of the subjective measures (Table 3). et al., 2001). CB1 and μ-opioid receptors not only are physi- A significant time–CBD interaction was evident for the posi- cally associated but also share Gi-alpha-mediated intracellular tive PANAS (F[14,105] = 4.96; P < 0.0001) and total OVAS signaling and interact to modulate neurotransmitter release (F[14,105] = 3.8; P < 0.0001) measures, but no significant in the nucleus accumbens (Schoffelmeer et al., 2006). Given group differences at individual times were observed after cor- the growing clinical interest in CBD, and in relation to ad- rection for multiple comparisons (data not shown). dictive disorders, future studies are needed to further explore the molecular mechanisms by which CBD may inhibit opioid- DISCUSSION seeking behaviors and endogenous opioid-mediated reward The main findings of this study were that CBD was well pathways. tolerated at doses up to 800 mg (approximately 10-15 mg/kg), There are limitations that must be considered with these with no significant pharmacokinetic changes with opioid coad- results. Our experimental design was subject to some degree of ministration. Plasma CBD Cmax and tmax were not significantly selection bias because of not studying pharmacokinetic prop- altered by fentanyl coadministration. Similarly, no effect was erties across all ages, sex, and ethnic backgrounds; however, evident for urinary CBD and metabolite excretion except at the the pharmacokinetic properties of CBD have already been ex- higher fentanyl dose in which CBD clearance was reduced. Im- amined and the main objective of this study was to assess portantly, fentanyl coadministration did not produce respira- CBD safety in combination with an opioid agonist. Moreover, tory depression or cardiovascular complications during the test whether these effects generalize to opioid-dependent individ- sessions, and CBD did not potentiate fentanyl effects. Further- uals and other relevant clinical populations are important to more, CBD clearance did not differ when coadministered with assess in the next phase of investigation. Self-report may have opioids. Our results add to the growing body of literature eval- led to bias via distortion of information either intentionally or uating the safety of CBD administration in humans. Together unintentionally, but our combination of self-report (eg, ques- with prior safety studies (Rosenkrantz et al., 1981; Consroe tionnaire) and objective measures (eg, vital signs, urine test- et al., 1991b; Zuardi et al., 1995; Tomida et al., 2006), these ing, and blood sampling) to examine eligibility criteria and the data show that CBD is well tolerated and safe, which is critical safety outcomes decreased such risk. Finally, we studied rel- for the development of CBD as a treatment intervention, even atively low to moderate doses of CBD and fentanyl and only in relation to opioid abuse. included participants who were not opioid dependent out of To assess the effects of CBD on subjects’ affect, we per- concerns associated with development of drug abuse behav- formed an exploratory analysis of validated subjective measure iors after administration in large doses. Although we cannot scales (PANAS and OVAS)(Watson et al., 1988) as well as anx- generalize our results to opioid-dependent patients, the toler- iety VAS. The results suggest that CBD at the doses examined ance to opiates that characterize such individuals may actually does not markedly alter affect, consistent with other reports decrease the risk associated with opioid intoxication compared (Fusar-Poli et al., 2009), or exacerbates fentanyl’s subjective with subjects with limited opioid exposure such as those in- effects. Further studies are necessary in larger populations to cluded in this study. fully discern CBD effects on mood across a large dose range. The potential to examine CBD in human opiate abusers is intriguing on the basis of results from our preclinical animal CONCLUSIONS data (Ren et al., 2009). It is predicted that CBD would have a Capsules of 400 and 800 mg of CBD did not exacerbate significant effect on inhibiting heroin-seeking behavior. How- adverse effects associated with IV fentanyl administration. ever, there are still large gaps of knowledge regarding CBD Coadministration of CBD and opioid is safe and well tolerated. actions in the brain, as this phytocannabinoid is much less The results of this study pave the way for future studies to

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