Is CBD a Trojan Horse for a Mainstreaming Alternative Medicine?

Cannabidiol (cbd) is a nonpsychotropic extract found in cannabis plants. One of more than 100 cannabinoids in cannabis plants, it has burst into the US marketplace over the past few years. Cannabinoids are active with cannabinoid receptors in the brain. For decades, the understanding of cannabinoids has been somewhat limited in mainstream medical and pharmaceutical research and practice circles because of the presence of tetrahydrocannabinol (THC), the psychoactive chemical that has played an outsize roll in the war on drugs. Because cannabis remains a schedule I substance at the federal level, CBD has found itself in a complicated and protracted public educational and regulatory quagmire.

What it Isn’t

Based on all available evidence, CBD cannot get people high, and it is produced legally in a number of countries. Yet it isn’t completely legal in most countries. Interestingly, some nations, such as China, are starting to cash in on production of the extracts but maintain some of the strictest laws against the use of the product(s) extracted from farming the cannabis or hemp plants. Canada, European countries, and other industrialized nations all have ambiguous, conflicting, and confusing postures on CBD and sometimes THC.

Importantly, although we are finally beginning to apply credible and more conventional scientific research to cannabinoids, we still can only guess about CBD’s mechanism of action.¹ The World Health Organization published an excellent resource on what CBD is and what it is not and where the world is heading with it.²

A Rapidly Emerging Market

Forbes reported this year that by 2024, CBD is expected to represent a $20 billion industry in the United States alone, as its wide array of delivery systems, such as cream, gummies, and oil, starts to hit mainstream retail shelves.³ Expect the local grocer to get involved because of CBD’s significant margins and the continued growth in social acceptance. Ironically, CBD may be found throughout stores but not necessarily in pharmacies. According to the same report, THC-based products are expected to add $25 billion to the cannabinoid market in states where it is legal though still federally illegal.³

Those sales will likely continue in dispensaries because mainstream investors do not want to look over their shoulders for the Drug Enforcement Administration during quarterly earnings calls.

Mainstream vs. Alternative Medicine

Although the arc of CBD products has been interesting to follow, the more significant trend may be the increasing acceptance of alternative types, outlets, and sources of alternative medicine, both pharmaceutical and otherwise. It seems that traditional Western medical models are becoming more open to Eastern models of health care delivery, much as fusion themes are popular at restaurants, with East and West often coming together. Significantly, CBD’s rise to acceptance, along with THC’s, began with patients with difficult-to-treat epilepsy and children with special needs. When mainstream medical solutions did not work, these patients and their parents turned to alternatives. Kids finding relief was apparently too much for regulators to hold the line.

CBD Is Not Alone

About 1 in 4 adults received massage therapy last year, and that industry has more than doubled in a decade to $18 billion.⁴ In the compounding pharmacy world, hormone therapies for peri- and postmenopausal women are wildly popular for those who have access to a compounding pharmacy and good women’s health resources. Physical therapy has also grown substantially over the past decade in its number of approaches to ailments and procedures and is now a $34.5 billion industry, which is expected to grow more than 6% annually, faster than the expected growth rate for hospitalizations, medications, and physicians’ services.⁵ Dry needling, myofascial cupping, and Rolfing, among other techniques, have emerged as mainstream only now, even though they have existed for decades, if not centuries, in some form or another. As with the craft beer industry, which existed for many decades before its recent market explosion, it took a change in access and consumer expectations to reach an inflection point.

Physicians write hundreds of thousands, if not millions, of prescriptions every year so patients can get their OTC medications using their health savings account or equivalent tax-protected accounts. That also includes all these “alternatives” to what we think of as traditional Western medicine. These “orders,” written to mollify the Internal Revenue Service, are also contributing to the mainstreaming of previously “alternative” medicines and procedures. As more and more Americans get priced out of expensive medications and procedures, expect them to seek alternatives.

Stuck Between Poor Margins and Regulatory Safe Harbor

Perhaps the most significant legislation affecting CBD, and potentially the housing and household goods marketplace, is the 2018 Farm Bill. Yes, you read that correctly. This federal bill restores the legality of growing hemp, which has low (>0.3%) to no levels of THC. Expect millions of acres of hemp production over the next decade, as CBD makes up just 23% of the hemp marketplace.⁶

Everyone seems to be getting relief from regulatory control of alternative therapies except pharmacies. The profit margins on physical therapy are 14.5% and are up to 60.0% or more on CBD. Farmers trying to weather soybean tariffs and who are happy to make $30 to $40 per acre can switch to hemp production and expect $300 to $350 per acre.⁷

Yet pharmacies are generally stuck with FDA-approved means of market entry. Although many pharmacies do sell CBD products, most boards of pharmacy remain skittish about endorsing them. In 2018, the FDA approved Epidiolex, a pure form of CBD that costs tens of thousands of dollars per year. This makes it inaccessible without insurance coverage, leading to rebate games and thus subjecting pharmacies to low, no, or negative margins—if pharmacies have access to it at all, as it will likely remain a specialty product.

What's Next?

Pharmacies would do well to take a hard look at the emerging alternative medicine marketplace, including services instead of just products. Examples of complementary and alternative medicine—friendly pharmacies are now in every state, and they may be part of the solution to sustainability in an increasingly difficult third-party-payer environment.

Troy Trygstad, PharmD, PhD, MBA, is vice president of Pharmacy Programs for Community Care of North Carolina, which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.

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References

• Campos AC, Moreira FA, Gomes FV, Del Bel EA, Guimarães FS (December 2012). "Multiple mechanisms involved in the large-spectrum therapeutic potential of cannabidiol in psychiatric disorders". Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences (Review). 367 (1607): 3364—78.
• https://www.who.int/medicines/access/controlled-substances/5.2_CBD.pdf
• https://www.forbes.com/sites/irisdorbian/2019/05/20/cbd-market-could-reach-20-billion-by-2024-says-new-study/#17d7752c49d0
• https://www.amtamassage.org/infocenter/economic_industry-fact-sheet.html
• https://blog.marketresearch.com/u.s.-physical-therapy-clinics-constitute-a-growing-34-billion-industry
• https://www.fb.org/market-intel/2018-farm-bill-provides-a-path-forward-for-industrial-hemp
• https://newfrontierdata.com/hemp/american-farmers-forget-soy-check-hemps-price-per-acre-help-us-win-china-trade-war/