By Chris Carmichael
CEO/Head Coach of CTS
Ever since writing this article on what athletes need to know about cannabidiol (CBD), we’ve been having a lot more conversations with athletes and researchers about CBD. One of those researchers is Joanna Zeiger, MS, PhD. If that name sounds familiar, you probably remember Joanna from her storied triathlon career. She excelled across different distances, placing 4th at the 2000 Sydney Olympics, winning two Ironman triathlons and finishing 5th at the 2000 Ironman World Championships, and winning the 2008 Ironman 70.3 World Championship. Following her athletic career, Joanna earned a Ph.D. from Johns Hopkins Bloomberg School of Public Health.
A 2009 cycling accident left Dr. Zeiger with severe chronic pain, for which she started using cannabis to mitigate symptoms and to aid with sleep. Learning more about cannabis and its medicinal possibilities, particularly in the climate of the opioid crisis, has driven Dr. Zeiger’s interest to study the plant; her emphasis is on patient outcomes and finding ways to improve the lives of those who suffer with pain.
Recently, Dr. Zeiger completed the Athlete PEACE Survey, which sought to examine the use of THC and CBD by athletes. More than 1200 athletes answered the survey, and I was happy to help recruit athletes by sharing the study information. With her research experience with cannabis for athletes, particularly in the area of pain management, I was eager to ask some more questions.
Key Takeaways from Dr. Joanna Zeiger
- Determine your goal with cannabis consumption.
- Consult a physician knowledgeable in cannabis use
- Educate yourself.
- Be responsible. Start low, go slow.
- Purchase products that have been tested by a state-regulated lab.
- Keep track of the effects cannabis is having on you.
- Don’t get frustrated if a product doesn’t work because there are plenty of others to try.
From the viewpoint of a cannabis researcher, what should athletes look for and watch out for when it comes to CBD products?
Athletes first need to decide whether there is a good reason to try cannabis. Use of any new supplement or drug must be considered carefully, because such products are not immune to potential adverse effects. I am a researcher on cannabis, and not a physician. There are physicians now who are more expert on cannabis use and can help manage its use. Before starting to use cannabis products, it certainly could help to have a conversation with one’s medical care provider or a physician specializing in cannabis to determine whether one has conditions that could worsen with its use.
Research is still needed to determine the optimal pattern and type of cannabinoid to use. Whether CBD-only, THC-only, or some combination of both are indicated for a specific condition are discussed in two good articles about the different cannabinoids and the difference between hemp and marijuana.
First, let’s talk about THC. In Colorado, if a consumer is purchasing a product with THC, it is going to be purchased from a dispensary. Products purchased at a dispensary have necessarily been tested at a state regulated lab and will have a Certificate of Analysis. This is really the optimal way to purchase cannabis because you know what you are purchasing.
CBD products are not regulated in the same way as THC products. CBD can be purchased at a dispensary where it has been tested. CBD can also be purchased on-line, at the grocery store, and even CVS will start carrying CBD products – products purchased in these ways are not necessarily tested. Since CBD does not have to go through the rigorous testing of THC, the consumer may not have full information on what they are purchasing. Make sure that you are purchasing from a reputable company that discloses a Certificate of Analysis. Purchase from companies that adequately put their ingredients and dosing information on the bottles or packaging. Be wary of companies that are making unsubstantiated claims about their products.
As the market for CBD-infused products grows, what types of products are more marketing than substance?
The world of CBD has blown up, that is certain. The CBD burger was a cute marketing stunt, but the growth of CBD infused products is undeniable. CBD is showing up in drinks, salves, all manner of food, and is being touted as the next best thing. It is really just too early to know the true medical impact of CBD. One of the factors is dosing. How much is a therapeutic dose? Is it 5mg or 500mg or somewhere in between? And, as mentioned above, since there may be a lack of testing of some CBD products, it may not be possible to know the true composition of CBD in some products. The best advice I can offer is to be an informed consumer and do some homework on the products you purchase and assure that a Certificate of Analysis is included.
Dosing information for CBD is vague at best. What dosage guidance can you provide for athletes looking to treat pain or improve sleep with CBD?
There is limited guidance on dosing of cannabis, whether it is CBD, THC, or combination use. Because of the federal restrictions on cannabis, there have only been a few small-scale clinical trials and even survey-based studies like the Athlete PEACE Survey study are uncommon.
The lack of information makes it confusing for consumers who have a medical need or are implementing cannabis for general wellness. There are many things to consider: route of administration (e.g. smoke, tincture, capsule, topical), frequency of use (e.g. less than daily, multiple times per day), and which cannabinoid combination to use (THC-only, CBD-only, co-use of THC and CBD).
Consider the Goal
When an athlete starts to consume cannabis, it is important to define what the goal is from cannabis. Is it pain-relief? Improved sleep? Decreased anxiety? Recreational? Muscle soreness? It could be some combination of these or other things, but understanding the why of cannabis use will help direct the athlete to the proper type of products.
The best information on specific dosing I have seen thus far came from a commentary in the Annals of Medicine.
“We propose that patients use oral formulations (such as capsules) for long-term relief, with tinctures for breakthrough pain. We suggest vaping for patients who prefer to inhale cannabinoids, because this method probably has fewer adverse effects than smoking. We advocate a “start-low, go-slow” dosing philosophy, applied to both quantity and adverse effect profiles. We recommend starting with CBD extract, 5 to 10 mg twice daily, to be increased weekly over 1 to 2 months until pain relief is achieved. If CBD extract alone provides insufficient relief, we suggest adding THC, 1.0 to 2.5 mg, and slowly titrating up as needed.”
Every cannabis consumer will need to figure out, hopefully with guidance with a knowledgeable physician, what works for them and this might entail some experimentation. Cannabis imparts a unique experience for each consumer, and what works for one athlete might not work for another. It is much like training – two people can follow the exact same training program and one athlete might thrive while the other can’t handle the training load.
The mantra in the world of cannabis is “start low, go slow”. This means starting at a low dose and adding more cannabis to that initial dose slowly over time.
A word of caution with edibles
If an athlete is using edibles with THC, particularly novice users, please remember it can take 45-75 minutes to feel the effects. Do not re-dose during that window! I have heard too many horror stories about people over-ingesting edibles because they were impatient with the onset of action. In addition, there has been an increase in emergency department visits for severe adverse effects that can include psychiatric symptoms, extreme vomiting, and cardiovascular events.
A final word. If needed, cannabis should be implemented carefully into an athlete’s life in order to maximize beneficial effects. However, cannabis is not innocuous – adverse effects can and do occur.
 Boehnke, K. F., & Clauw, D. J. (2019). Brief Commentary: Cannabinoid Dosing for Chronic Pain Management. Annals of internal medicine.