Chronic use of over-the-counter pain relievers (i.e. NSAIDs like ibuprofen and naproxen sodium) poses greater health risk than previously known, and we are in the midst of an epidemic of opioid addiction and overdoses that kill tens of thousands of Americans annually. In such a landscape, athletes are rightly curious about and eager for cannabidiols’ (CBD) promises of pain relief and reduced inflammation without the risks associated with NSAIDs or opioids.
Are CBD products right for you? There’s a lot here to unpack and consider, so get comfortable and read on.
Is CBD legal for athletes?
Yes. Starting at the beginning of 2018, the World Anti-Doping Agency (WADA) removed CBD from the list of prohibited substances – in or out of competition. (Here is the 2020 WADA Prohibited List.) The US Anti-Doping Agency (USADA) did the same, and they provide a “Marijuana FAQ” page to clarify the rules. There is an important caveat: ONLY CBD was removed from the prohibited list. The psychoactive component of marijuana, THC, is still prohibited in competition, as are synthetic cannabinoids. The specific wording is: “All natural and synthetic cannabinoids are prohibited, e.g.: In cannabis (hashish, marijuana) and cannabis products. Natural and synthetic tetrahydrocannabinols (THCs). Synthetic cannabinoids that mimic the effects of THC. Except: Cannabidiol.”
Interestingly, WADA set a urinary threshold of 150 nanograms per milliliter for THC, which is substantially more lenient than the previous limit of 15 nanograms per milliliter. The higher threshold is designed to lower the risk of an athlete testing positive due to casual use outside of competition. A USA Today article in 2016 quoted Ben Nichols, a spokesperson for WADA as saying, “Our information suggests that many cases do not involve game or event-day consumption. The new threshold level is an attempt to ensure that in-competition use is detected and not use during the days and weeks before competition.”
As for legality outside of sports, that’s a whole different matter. The federal, state, and local legality of cannabis and related products is constantly evolving. Check the laws in your area.
Athletes can legally consume cannabidiol, but what is it, what does it do, and why would you use it?
To begin with, cannabinoids already exist in your body. Scientists have identified what they call the endocannabinoid system (ECS) that modulates the activity of neurons. (9) Cannabidiol (CBD) is a phytocannabinoid found naturally in the cannabis plant. Unlike THC, which is also found in cannabis, CBD is not psychoactive.
Beyond that, scientists understanding of how the ECS works and how CBD influences it is still evolving. For a long time, research in this area was hard to complete due to the legal status of marijuana. However, based on recent studies and 2018’s The Essentials of Pain Medicine, Fourth Ed., here are the basics (5).
Within your nervous system, two endocannabinoids (2-AG and EAE) are produced in postsynaptic neurons (downstream) and released into the synapse. They bind to CB1 and CB2 receptors on the presynaptic neuron (upstream) and act to inhibit the release of certain neurotransmitters. For instance when CBD is used to treat epilepsy, it may reduce seizure activity by – in part – reducing the buildup of glutamate, an excitatory neurotransmitter.
CB1 receptors are found throughout the brain, spinal cord, and other tissues. CB2 receptors are as well, but more of them are found in immune system tissues. CBD binding to CB1 receptors has a greater effect the central nervous system, and CBD binding to CB2 receptors has a greater effect on reducing inflammation.
The primary purpose of the ECS appears to be maintaining homeostasis, which it does by keeping neurotransmitter levels in check. Consuming CBD could be thought of as supplementing or increasing the activity of your body’s existing endocannabinoid system.
As an athlete you apply greater stress to your body, leading to pain and inflammation greater than what your endocannabinoid system can handle. Adding exogenous CBD may help this overloaded system get your neurotransmitters back under control and help athletes maintain homeostasis.
6 Benefits of CBD for Athletes
Studies have shown cannabis (mostly THC and far less CBD) is effective for reducing pain, including musculoskeletal pain from exercise, as well as stiff joints. (5) There is little research on CBD alone or a 1:1 ratio of THC to CBD. This is an area where anecdotal evidence and biological plausibility are the best we have until research catches up. Despite the lack of hard evidence, CBD does appear to relieve pain effectively for many athletes.
Alternative to NSAIDs
Athletes have been consuming over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil) and naproxen sodium (Aleve) for decades, but they may not be as safe as we once thought. Ultradistance athletes, in particular, are typically advised to avoid NSAIDs during long training sessions and events, due to increased risk of renal damage. But even if your workouts and events are short, long-term or frequent use of NSAIDs may increase your risk for heart attack and stroke.
Some athletes have found the pain-relieving effect of CBD can reduce or eliminate their use of NSAIDS for exercise-related pain, with minimal side effects. According to The Essentials of Pain Medicine, Fourth Ed., “There are no documented deaths from cannabis or cannabinoid-based products. In a systemic review of studies of oral and oral-mucosal cannabis for various medical conditions, the majority of adverse events reports were considered non-serious (96.6%).”
Alternative to Opioids
According to the CDC, in 2016 opioids were involved in more than 42,000 deaths in the US. Opioid pain medications (i.e. morphine, codeine, oxycontin) are highly effective for pain management, but carry a significant risk of addiction and death by overdose. Cannabinoids are not as effective as opioids for relieving acute, high-intensity pain (5), but maybe effective for long-term pain management – either alone or in conjunction with other medications – with far less risk of dependence or accidental death.
A little bit of inflammation can be good for athletes and help stimulate positive training adaptations. Too much inflammation hinders recovery and hurts performance. There are CB2 receptors in both the brain and periphery, but they are more concentrated in immune tissues. Cannabinoids binding to CB2 receptors may have an anti-inflammatory effect by reducing cytokine (cell messengers) production. (8) In other words, CBD bound to CB2 receptors help dial down the response when your immune system sounds the alarm after hard workouts.
Settle your gut
Inflammation in the small and large intestines causes a lot of discomforts, and GI distress is one of the leading reasons endurance athletes drop out of races. CBD won’t solve stomach problems from dehydration and overheating (two major causes for athletes), but if you have underlying inflammation issues that contribute to gut problems during or after exercise, CBD may be effective for reducing your symptoms. There are CB1 and CB2 receptors in the colon. Colitis symptoms were inhibited (in mice) when CB1 and CB2 receptors were activated. (8)
Improve Sleep Quality
Getting more and better sleep is one of the most effective ways an athlete can achieve greater training gains. Anecdotally, athletes who consume CBD report greater ease going to sleep and a more restful night’s sleep. One potential reason for this could be CBD inhibiting the reuptake of adenosine. (7)
Adenosine triphosphate (ATP) breaks down as your brain burns carbohydrates for energy, and adenosine gradually accumulates in the brain. More adenosine binding to neurons inhibits the release of neurotransmitters, slowing down brain activity, helping you feel calmer, and inducing sleep. Your body metabolizes adenosine as you sleep, and sometime later, low concentrations of adenosine help you wake up and the process starts again.
By binding to the same receptors adenosine would bind to, CBD may inhibit adenosine reuptake, which helps it accumulate more quickly and makes you feel sleepy sooner. CBD may also have a potent anti-anxiety effect for some people, which can help them get to sleep and have a more restful sleep.
How to use CBD
New CBD-containing products hit the market every week. You can get ingest CBD through capsules, pills, or as an oil. You can inhale it as a vapor. It has been infused into sports drinks, recovery drinks, and all manner of edibles. There are also topical creams and lotions that contain CBD oil, as well as tinctures/drops that can be placed under your tongue.
How you consume CBD may affect how quickly you experience its effects. Capsules, oil, and edibles have to be digested, so they may take a bit longer. Topical creams are said to be quicker than edibles, and sublingual drops/tinctures are said to be the most rapid (besides inhalation via vaping).
CBD is available as “full-spectrum” or “isolate”. Full-spectrum CBD products contain CBD and other compounds found in the original plant, which could include small amounts of THC. If the CBD was derived from industrial hemp, the THC content of the original plant is legally supposed to be less than .3% (in Colorado). Products that contain CBD isolate should only contain CBD. CBD isolate and CBD produced from hemp would be a better choice, from an anti-doping standpoint, for anyone with zero-tolerance drug testing at work (i.e. pilots).
How much CBD to use
Here’s where things get tricky. There is no standard dose that delivers a consistent effect for all people. CBD products are not well regulated, so there can be inconsistencies in how much CBD is in a product. And depending on how you consume CBD (oil, gummy bear, cookie, recovery drink, tincture, vapor), it can be difficult to be precise. The most precise way to consume CBD is probably through capsules, or by calculating how many milligrams of CBD are in a given volume (i.e. 1 milliliter) of a tincture.
Companies that produce and sell CBD products recommend starting with a low dose and gradually increasing it based on the effects you experience.
Conclusion and Caveat
The emergence of cannabidiol could mark a major turning point in how athletes recover from training stress and manage both occasional and chronic pain. The giant, glaring caveat is that right now the use of CBD and the ways it’s being delivered are ahead of the science. There is a lot still to learn about how CBD works and how to best utilize it with athletes. That is not unusual, though. Back when carbohydrate-rich sports drinks first came out, it was clear they were helping improve performance even if the formulas weren’t perfect and the mechanisms weren’t all known.
Although it is not a banned substance for athletes in or out of competition, the potential risk for athletes is if the product you buy doesn’t contain what it says on the label. If it actually contains a significant amount of THC or other prohibited substance, you are at risk for a doping violation. As with anything else, it will be up to you to research and find a reputable brand.
With what we know at this point, CBD offers good potential benefits and few risks. If it improves recovery as a pain reliever, anti-inflammatory, and sleep aid, then it has great potential to improve athletic performance. And if it gets athletes to reduce consumption of NSAIDS, opioids, and prescription sleep aids, those are even bigger victories.
References & Resources
- Booz, George W. “Cannabidiol as an Emergent Therapeutic Strategy for Lessening the Impact of Inflammation on Oxidative Stress.” Free Radical Biology and Medicine, vol. 51, no. 5, 2011, pp. 1054–1061., doi:10.1016/j.freeradbiomed.2011.01.007.
- Elman, Igor, and Scott E. Lukas. “Effects of Cortisol and Cocaine on Plasma Prolactin and Growth Hormone Levels in Cocaine-Dependent Volunteers.” Addictive Behaviors, vol. 30, no. 4, 2005, pp. 859–864., doi:10.1016/j.addbeh.2004.08.019.
- Filippis, Daniele De, et al. “Cannabidiol Reduces Intestinal Inflammation through the Control of Neuroimmune Axis.” PLoS ONE, vol. 6, no. 12, 2011, doi:10.1371/journal.pone.0028159.
- Gorzalka, Boris B., et al. “Regulation of Endocannabinoid Signaling by Stress: Implications for Stress-Related Affective Disorders.” Neuroscience & Biobehavioral Reviews, vol. 32, no. 6, 2008, pp. 1152–1160., doi:10.1016/j.neubiorev.2008.03.004.
- Halawa, Omar I., et al. “Role of Cannabinoids in Pain Management.” Essentials of Pain Medicine, 2018, doi:10.1016/b978-0-323-40196-8.00056-5.
- Hammell, D.c., et al. “Transdermal Cannabidiol Reduces Inflammation and Pain-Related Behaviours in a Rat Model of Arthritis.” European Journal of Pain, vol. 20, no. 6, 2015, pp. 936–948., doi:10.1002/ejp.818.
- Murillo-Rodriguez, Eric, et al. “Anandamide Enhances Extracellular Levels of Adenosine and Induces Sleep: An In Vivo Microdialysis Study.” Sleep, vol. 26, no. 8, 2003, pp. 943–947., doi:10.1093/sleep/26.8.943.
- Nagarkatti, Prakash, et al. “Cannabinoids as Novel Anti-Inflammatory Drugs.” Future Medicinal Chemistry, vol. 1, no. 7, 2009, pp. 1333–1349., doi:10.4155/fmc.09.93.
- Pacher, P. “The Endocannabinoid System as an Emerging Target of Pharmacotherapy.” Pharmacological Reviews, vol. 58, no. 3, 2006, pp. 389–462., doi:10.1124/pr.58.3.2.
- Patricia H. Reggio, “ Endocannabinoid Binding to the Cannabinoid Receptors: What Is Known and What Remains Unknown”, Current Medicinal Chemistry (2010) 17: 1468. https://doi.org/10.2174/092986710790980005
- Xiong, Wei, et al. “Cannabinoids Suppress Inflammatory and Neuropathic Pain by Targeting α3 Glycine Receptors.” The Journal of Experimental Medicine, vol. 209, no. 6, 2012, pp. 1121–1134., doi:10.1084/jem.20120242.