June 2019 Writer \/\/ Janelle Morrison Photography \/\/ Laura Arick While there may not be controlled clinical studies being conducted proving that cannabidiol (CBD) effectively treats generalized anxiety disorders, there are theories among medical professionals, research and personal testimonials that claim CBD products are not a placebo scam but have measurable effects on people being treated for PTSD, depression, social anxiety disorder, sleeping disorders, etc. I had a conversation with Dr. Christopher \u201cChris\u201d Bojrab, president of Indiana Health Group (IHG), the largest multidisciplinary behavioral health private practice in Carmel, Indiana, established in 1987. We discussed his opinion of CBD and on treating his patients with CBD oil and topical products. Bojrab attended Wabash College and Indiana University School of Medicine. He was named Top Doctor by peers in \u201cIndianapolis Monthly Magazine\u201dand was awarded Distinguished Fellowship by the American Psychiatric Association. He is a board-certified psychiatrist who treats child, adolescent, adult and geriatric patients. His areas of interest include psychopharmacology, mood and anxiety disorders, ADHD, sleep disorders, pain syndromes and gambling addiction. Bojrab has also served as a delegate to the American Medical Association and as Indiana\u2019s representative to the American Psychiatric Association for several years. He currently serves on the board of directors of the Indianapolis Medical Society. \u201cI am hugely interested in science-based medicine,\u201d Bojrab stated. \u201cI am, by nature, an incredibly skeptical person. Initially, I was probably negatively predisposed towards the whole idea about CBD. I had been contacted by friends and colleagues of mine who have been using it as part of their practice, and these folks, while they are good doctors and I respect their opinions, they tend to do more nontraditional medical treatments than what I do at our practice.\u201d IHG has over 50 highly trained multidisciplinary professionals who are able to provide a team approach for the treatment of almost all behavioral health issues in children, adolescents, adults and seniors. A skeptic right out of the gate, Bojrab didn\u2019t subscribe to the growing popular opinion that CBD was beneficial to anyone, let alone his patients. However, since many of his patients were asking and\/or taking CBD products, he decided to \u201cdig into\u201d some of the \u201cresearch\u201d that is out there. \u201cUnfortunately, in comparison to a pharmaceutical product, there\u2019s not nearly the type or quality of research that there is for things that go through a FDA approval process,\u201d Bojrab admitted. \u201cWith that being said, if you look at the work that has been done, I was struck by a couple of things: What we do know about the endocannabinoid system now certainly lays the groundwork for a prior plausibility as to why these types of substances could have physiologic effects and could have at least some of the benefits that they are reported to have. It also looks like it is possible to get enough of this stuff into people, depending on the type and the concentration, primarily the absorption that you see with these products, that it could reach reasonable physiologic levels where one might expect to see those effects.\u201d Bojrab was still teetering on his opinion as he was listening to what his patients were telling him over the course of a year. \u201cTheir feedback became an increasingly compelling story,\u201d Bojrab said. \u201cBut I\u2019m also the first person that would tell you that the plural of anecdote is anecdotes and not data. So, I\u2019m sensitive to the fact that we all have our own biases and preconceptions, and we\u2019re all vulnerable to confirmation bias as much as we try to be cognizant and guard against it. I was seeing so many patients come in, many I\u2019ve known for five, 10, 15-plus years, who were having fairly striking responses to CBD. It\u2019s not a panacea; it doesn\u2019t work for everybody. But it seems to have a reasonably high hit rate and most commonly in the things that are probably best supported from the literature as to what it should do.\u201d According to Bojrab, he tends to see CBD having the best \u201chit rate\u201d for pain, anxiety and for sleep. \u201cPeople ask me about its use for depression\u2014I think it\u2019s been a little hit or miss there,\u201d he said. \u201cSome people have reported benefit. People sometimes ask me about the anticancer effects; I tell them that there is some in vitro data where that might be the case, but we\u2019re just not sure how clinically meaningful it is in a real-life person. There certainly is a good database targeting certain types of seizures in patients.\u201d After witnessing enough benefits and improvements as a result of CBD treatments through his own patients, Bojrab started carrying a brand of CBD in his practice a couple of years ago. A sufferer of chronic back pain, Bojrab started taking CBD personally to see if it would have any effect on his morning back pain routine. \u201cWithin four to five days of when I started taking it, I\u2019d say that morning pain was 75% improved,\u201d Bojrab shared. \u201cAnd it has continued to stay that way. The other big thing I noticed, I\u2019m somebody who rarely remembers their dreams. Ever since starting this, I remember my dreams every night, which is probably a marker for improved sleep quality.\u201d There is a large retrospective case series published by The Permanente Journal that details a psychiatric clinic\u2019s clinical application of CBD for anxiety and sleep complaints as an adjunct use to usual treatments. The conclusion was that \u201ccannabidiol may hold benefit for some anxiety-related disorders\u201d but stressed that controlled clinical studies are needed. \u201cThe person that sort of pushed me over the edge to where I said, \u2018OK, we\u2019re going to start carrying this , was the mother of a patient\u2014a young woman that I\u2019ve seen for a number of years who has pretty significant anxiety and OCD,\u201d Bojrab said. \u201cThey are a delightful family, and her mom is an absolute sweetheart that has terrible problems with arthritis and fibromyalgia. Whenever I see them in the office, it almost always went the same way. I would go out into the waiting room\u2014my patient is always accompanied by her mom\u2014and they\u2019re always full of smiles when I see them. Her mom would then very slowly get up out of her chair, while grimacing, and she would walk the perimeter of my waiting room, holding onto a piece of furniture or on to the wall. She would hold on to the wall as we would go down the hallway and into my office. Then she would grimace her way into one of my chairs and would have our appointment with her daughter. Then one time, I went into the waiting room and greeted them both the same way as before, but her mom just popped up from out of the chair that she was sitting in, in the waiting room, then walked down the center of the hallway into my office without holding onto anything and then pops down into the chair without grimacing.\u201d Astounded, Bojrab turned to his patient\u2019s mother and exclaimed, \u201c\u2019What\u2019s up with you?\u2019 She sheepishly smiled at me and told me that I was going to think she was \u2018nuts,\u2019 and she said, \u2018I started taking CBD.\u2019 I told her that I\u2019d been looking into it over the past year and asked her to tell me about her experience.\u201d She explained to Bojrab that she had been to see her orthopedic surgeon because her knees were causing her enough pain that she was going to need surgery. She had even tried to convince her surgeon to operate on both knees at the same time. Even though her pain was so severe, her surgeon convinced her to schedule surgery on the worst knee, and then he would operate on the second after her three-month rehabilitation from the first surgery. \u201cShe told me that she had scheduled the surgery to have one of her knees and had picked up the brand of CBD that we now carry, and she started taking it,\u201d Bojrab recalled. \u201cShe told me that she canceled the surgery within a week because that\u2019s how much better her knees were feeling, and she said that this was the best her fibromyalgia had felt in 30 years. She said she\u2019ll have to have surgery at some point, but she went from considering having both done at once because of the amount of pain she was in to holding off until she absolutely needs it. That was the tipping point for me.\u201d Since then, Bojrab has had three patients and one husband of a patient who were all scheduled for knee replacement surgery cancel their surgeries after starting the CBD supplement. \u201cNow in fairness, I\u2019ve also given it to a number of people where it hasn\u2019t done a damn thing, but that\u2019s just the same for any of the medications I prescribe,\u201d Bojrab stated. \u201cSo again, I hold my guard against making it sound too magical or too over the top because it\u2019s not everything to everybody. There certainly exists an understanding of the mechanism of action involved to where it makes sense, especially with things like anxiety, pain, sleep and certainly with seizures. It seems to have a high enough hit rate that I think it makes a reasonable thing for patients to consider. I sure would like it more if we had more double-blind placebo-controlled trials because the placebo effect is pretty powerful.\u201d Bojrab said of his patients who experience positive results with CBD, they notice them within the first few weeks of taking CBD oil and\/or related products. \u201cOne of the things that I see being marketed to patients is that they are told that they should take it for six months or 12 months or 18 months, and you know, even a broken clock is right twice a day,\u201d he quipped. \u201cThe longer you keep people on anything, the more likely it is to \u2018work\u2019 because the natural history of most disease states is resolution. I like the fact that when it works, it seems to work pretty quickly. If within the first month, you\u2019re not noticing much difference, I don\u2019t have high hopes that it\u2019s going to be a robust treatment for you.\u201d When asked if he is aware of any side affects from CBD oil or CBD products, Bojrab replied, \u201cCBD can have drug interactions. Interestingly, and we probably know this best from the seizure literature, the doses that most people are taking for nonseizure types of symptoms are probably low enough that the chances of a meaningful drug interaction are quite low\u2014not that they\u2019re zero, but quite low.\u201d How much CBD does one take and can it have an adverse effect on other prescription medications? \u201cNormally when you go to your doctor and they give you a bottle of pills, it will say, for example, 200 mg of Lamictal or 100 mg of Topiramate\u2014that is the number of milligrams per dose or per pill,\u201d Bojrab explained. \u201cFor CBD, that\u2019s the number of milligrams in the whole bottle. So, a 500 mg bottle of CBD actually gives you 16.67 mg per 1 ml dose. The doses that were approved to treat the two refractory childhood seizure disorders,were 400 to 800 mg per dose. At those kind of levels, you can see drug interactions where it can even raise or lower the dose of other anticonvulsant medicines, so especially for people who are thinking about taking it for seizures, if they\u2019re thinking about those higher doses, they really need to talk with their neurologist about that.\u201d Bojrab agrees that anytime a person is on any type of prescription medication, they should first consult with their doctor before taking CBD products. \u201cPeople sometimes fall prey to this naturalistic fallacy that because it came from a plant that it\u2019s natural and if it\u2019s natural, it\u2019s safe. Plutonium is natural, and nothing is more natural than being mauled by a bear, so just because it\u2019s from nature doesn\u2019t mean it\u2019s safe.\u201d Indiana health group is one of the premier behavioral health care private practice organizations in the Midwest and the largest in the state of Indiana. IHG provides state-of-the-art comprehensive behavioral health care outpatient services and treatments for ADD\/ADHD, anxiety, depression, eating disorders, OCD, adjustment disorders, blended family, caregiver stress, divorce, grief\/loss, parenting, anger management, communication issues, marital issues and more. For more information on IHG, visit indianahealthgroup.com. Disclaimer: CBD supplements are not designed to cure any symptoms or diseases, and due to FDA regulations, NO product claims can be made as a \u201ccure\u201d for specific diseases.