The medicinal use of cannabis has been recorded for millennia, dating back to Emperor Shen Neng of China in 2737 BCE. In 1993, the mummy of the Princess of Ukok, better known as the Siberian Ice Maiden, was discovered by Russian archaeologists in Southern Siberia. Along with her 2500-year-old remains, a pouch of cannabis was found, which scientists speculate was used to cope with her symptoms of breast cancer and other ailments [19]. While more than 100 different cannabinoids within the marijuana plant contribute to its therapeutic potential, THC and CBD remain the most well-studied [4, 8, 20].

THC is the primary psychoactive cannabinoid acting as a partial agonist of CB1 and CB2 receptors of the endocannabinoid system (ECS). CBD acts as a primary allosteric modulator of CB1 and CB2 receptors, enhancing the activity of the endogenous ECS; however, CBD is reported to be devoid of psychoactive effects [8, 21, 22]. This allosteric modulation by CBD has also been shown to inhibit THC-elicited psychotomimetic potential and cognitive impairments [21, 23, 24]. Considering emerging evidence of CBD's potential analgesic, anxiolytic, and neuroprotective effects, its lack of intoxicating effects makes it ideal for medicinal use [8].

Recent physician survey studies have conveyed growing acceptance among various specialties about the recreational and therapeutic uses of CBD and cannabis [13–17]. Respondents in our study appear to have generally favorable attitudes towards CBD and cannabis, with most respondents favoring the legalization of medicinal and recreational cannabis. More interestingly, this study demonstrates that sports medicine providers recommend CBD and cannabis products for various therapeutic purposes, primarily chronic musculoskeletal and neuropathic pain. Over the last few decades, there has been ample medical literature demonstrating improvements in symptoms related to chronic musculoskeletal and neurologic conditions using CBD and cannabis (i.e., fibromyalgia, spasticity, cancer-related pain) [25–27]. For example, a recent survey study of 878 patients with fibromyalgia reported that 72% of respondents substituted CBD for pain medications, mainly opioids or benzodiazepines, primarily substituting for harm reduction (i.e., fewer side effects) [28]. Similarly, in 2017, 595 Parkinson's disease and multiple sclerosis patients were surveyed, and 44% reported cannabis use for therapeutic purposes with high efficacy and lowered self-reported disability and prescription drug use [29]. More providers within our study recommended CBD compared to cannabis, 40.8% vs 24.8%. The reasons are not entirely clear from this study, but given the overall safety profile of CBD, its lack of “intoxicating” effects, and the general infiltration of CBD into mainstream consumer products, providers may see CBD as a safer option for patients compared to Cannabis and THC-containing products [30].

When we examined the factors potentially influencing CBD and cannabis recommendations of survey respondents, the community/private practice setting had a higher likelihood of recommending CBD and cannabis products for therapeutic purposes than the academic setting. In addition, respondents practicing in rural locations were much less likely to recommend cannabis products than those practicing in urban locations. One could speculate over an exhaustive list of socioeconomic and political factors which may play into these findings, but it is unclear from this study. The most important aspect of these findings is that other expected factors, notably age, gender, and primary specialty (apart from pediatrics), did not appear to influence the CBD or cannabis recommendations of survey respondents. Why is this important? Perhaps this reflects a growing acceptance of cannabis and CBD concerning their more evidence-based applications among providers; however, when examining perceptions of cannabinoids and sports performance, exciting age and gender differences were observed within our study.

Recent cases involving elite athletes have brought renewed attention to the debate over cannabis and whether it should be considered “doping” in sport. There is inconclusive evidence about any direct performance-enhancing effects of cannabis or CBD in athletes [31]. Despite WADA removing CBD from the prohibited substance list in 2018, cannabis remains prohibited in competition by WADA and many other professionals and international organizations. Most respondents in our study favored WADA removing cannabis from the prohibited substance list; however, older female providers were significantly less likely to favor this decision. Interestingly, to account for these age and gender differences, we found that male respondents were significantly less likely to view cannabis as performance-enhancing. In addition, older respondents were more likely to view cannabis and CBD as detrimental to performance and the integrity of sports. When looking closer at these perceptual differences, we saw an interesting distinction between CBD and cannabis.

Following the shift from being a prohibited to an allowed substance, CBD has quickly become a booming multibillion-dollar industry in sports. Several professional athletes have new lines of CBD products marketed for various claims, including pain relief, improvements in sports performance anxiety, and postexercise recovery [6, 20]. Leas et al. revealed that in April 2019, Google searches for CBD surpassed acupuncture by a factor of 7.49, meditation by 3.38, exercise by 1.59, and marijuana by 1.13 with 6.4 million searches [2]. Has this surge influenced sports medicine providers to think differently about CBD in sports? While older respondents in our survey were significantly more likely to think CBD is detrimental to performance, only 9.9% of our respondents believe CBD is detrimental to performance and the integrity of sport, compared to 39% with cannabis. The reasons for this discrepancy are unclear from this study, but these perceptions may influence how sports medicine providers counsel their athletes using CBD products. It is important to note that the ergogenic versus ergolytic effects of CBD compared to cannabis are still largely unknown; therefore, these perceptual differences can largely, if not exclusively, be attributed to marketing and advertising. In addition, one must recognize the seemingly ubiquitous addition of CBD to countless consumer products, which may also contribute to this evolving distinction.

There are several limitations to this study. First, the study design is only one data point; therefore, the overall trends of CBD and cannabis recommendations by sports medicine providers increasing or decreasing in the current culture are uncertain. It would be interesting to reevaluate these questions in five to ten years to observe any trends given the evolving legal landscape, social acceptance, and relative integration of CBD and cannabis into mainstream culture. The small sample size accounts for approximately 7% of AMSSM membership. However, the demographic distributions of our survey follow very closely with membership distributions (i.e., 71% of AMSSM have family medicine as their primary specialty, with our survey having 69% family medicine respondents). Lastly, although the survey was anonymous, this is still considered a fringe topic by many in sports medicine and medicine in general, which may limit the divulgence of actual behaviors and attitudes of respondents. Regardless of these limitations, 98% of respondents in our survey agreed to learn more through continuing education, recognizing that these cultural shifts are certainly not going away.