Debunking Cannabidiol as a Treatment for COVID-19: Time for the FDA to Adopt a Focused Deterrence Model?

Many cannabidiol (CBD) retailers make unsupported medical claims about their product. In recent years, the U.S. Food and Drug Administration (FDA) has sent warning letters to CBD retailers who promoted CBD to treat Alzheimer’s disease, cancer, diabetes, and other serious conditions for which there is no evidence of its efficacy as a treatment or preventive. Compliance with these warning letters has been low. During the novel coronavirus disease 2019 (COVID-19) pandemic, the FDA has begun sending more strongly worded warning letters that appear to have better compliance in that most of these companies have removed COVID-19-related claims. However, many continue to present other unsupported medical claims on other serious medical conditions like cancer, depression, addiction, and bone fractures, among many others. We argue that adopting a strategy of focused deterrence where the FDA prioritizes enforcement related to COVID-19 claims - but when COVID-19-related claims are found, pursues all other violations by that company - would present an opportunity to efficiently cut down on harmful claims overstating CBD’s benefits.


Editorial
Over the past few years, the U.S. Food and Drug Administration (FDA) has sent warning letters to some cannabidiol (CBD) retailers instructing them to cease making unsubstantiated therapeutic claims regarding many diseases, including cancer, addiction, and diabetes [1]. These letters asked recipients to respond in writing within 15 days and appear to have been largely ignored, as CBD retailers continue making unsupported claims about their product's ability to treat or prevent a variety of serious conditions. In March, the FDA began responding to unsupported therapeutic claims about CBD and novel coronavirus disease 2019 (COVID-19) by sending more strongly worded warning letters that instruct recipients to withdraw such claims within 48 hours [1]. The FDA has limited regulatory capacity to police the numerous CBD retailers and the even larger number of unsupported therapeutic claims about CBD and other cannabis-derived products, so it is worth considering whether this is an efficient, high-impact strategy [2,3].
To examine whether COVID-19-related letters led to faster and more complete compliance, on April 30, 2020, we reviewed the websites and social media of all CBD retailers who received an FDA warning letter in 2019 or 2020. We expected that a greater proportion of CBD manufacturers that received the strongly worded COVID-19-related warning letters would have removed unsupported medical claims compared to CBD manufacturers that received the letters regarding other unsubstantiated therapeutic claims. We compared the proportion of companies that removed claims or added prominent disclaimers (i.e., positioned near the product and stating that the FDA had not evaluated the claims and products were not intended to diagnose, prevent, or treat disease) by type of warning letter.
In 2019 and 2020, the FDA sent 18 letters to companies about "Unapproved New Drugs/Misbranded/Cannabidiol (CBD) Products." The recipients included manufacturers and retailers, with many companies doing both. Notably, at least one of the recipients (Curaleaf, Wakefield, MA) operates cannabis dispensaries around the United States in addition to selling CBD online via Curaleaf Hemp, which was cited in the 2019 warning letter. As of April 30, 2020, half (nine) of these companies still marketed CBD as treating or preventing disease without disclaimers. Between March 6, 2020, and April 27, 2020, the FDA sent COVID-19-related warning letters related to 38 companies, 21% (eight) of which had CBD products for sale on their website. As of April 30, 2020, six of the eight companies had either removed the COVID-19-related statements or added prominent disclaimers on the same page as the statements.
However, half of these companies had other medical claims similar to those for which the 2019 companies had been cited (Table 1). Conversely, three of the companies that received letters in 2019 had recently added new content marketing CBD products as protective against COVID-19, or claiming CBD improves immunity generally.

Food and Drug Administration
CBD, cannabidiol; PTSD, posttraumatic stress disorder; TBI, traumatic brain injury Our rapid online review comparing the compliance with these two types of FDA warning letters suggests that the FDA might profitably adopt a "focused deterrence" strategy, which police sometimes use to deter gang violence [4].
A focused deterrence strategy involves publicly telling potential offenders what the number one enforcement priority is (in the police case, typically gun violence; in this case, COVID-related claims) and if anyone breaks the rule, the offender is investigated for all transgressions, even otherwise low-priority ones. A focused deterrence strategy has two effects. First, because the certainty that penalties will occur is more deterrent than a probabilistic threat of even severe punishment, announcing that COVID-19 is the highest priority will prevent other CBD retailers from making such claims in the first place. Second, the marginal cost of expanding enforcement when intervening against CBD claims (i.e., expanding said letters to cover all of that same retailer's unsupported claims about a range of diseases) is modest, allowing the FDA to completely clean up the worst actors in the industry.
Our review highlighted a few other ways that focused deterrence adopted during a pandemic could have lasting effects even after the acute threat of COVID-19 has diminished. (1) The FDA might consider requiring a response within 48 hours for all misbranded CBD drug products. (2) Several of the companies that received warning letters in 2019 had removed the original offending content but were now selling products aimed at treating or preventing COVID-19 ( Table 1). These types of claims and promotions presumably fall under the area of what companies were instructed to avoid in the future. Publicly adopting focused deterrence can reinforce the gains made by earlier enforcement without having to necessarily individually recontact the CBD companies that have been previously cited. (3) The FDA may consider expanding letters to cover all websites operated by a company it is citing. Curaleaf provides a useful example. Cited in July for its subsidiary Curaleaf Hemp, Curaleaf manufacturers CBD and cannabis products and operates dispensaries in several states. The dispensaries were not mentioned in the warning letter, and despite removing CBD-related medical claims from the cited website, medical claims about cannabis products were still present on Curaleaf's state websites and social media as of April 30, 2020. Again, it would require only marginal additional resources for FDA to expand the warning to cover all such claims from a retailer, including when they are made on a different subsidiary's website.
In conclusion, we found that FDA letters regarding non-COVID-focused claims by CBD retailers have made little impact -few letters have been sent and nearly half have been ignored. But the stricter COVID-19 letters were complied with at a higher rate, despite the much shorter time window since they were sent. However, the fact that about half of the retailers that received COVID-19 letters still had other unsupported medical claims on their websites or social media is concerning. This suggests that significant public health benefit at marginal cost could be garnered if FDA letters sent in response to COVID-19 claims were amended to encompass all unsupported therapeutic claims made by recipients. Moreover, making it explicit and public that this focused deterrence strategy was being employed could prevent the industry as a whole from making COVID-19-focused claims in the first place.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: CLS was supported by National Institute on Drug Abuse under grant T32 DA035165, and the Wu Tsai Neurosciences Institute at Stanford University. KH was supported by grants from the U.S. Veterans Health Administration and the Wu Tsai Neurosciences Institute. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.