CBD and Massage

By Julie Crispin, with Karrie Osborn

Promises of Pain Relief (and a Potential $100 Billion Market)1 Make Cannabidiol a Lucrative Option for Clients and Therapists, But Is It Right For You?

Spas across the country have started offering cannabidiol (CBD) massages, franchises are looking for CBD product lines to incorporate into their new services, and product manufacturers are scrambling to get product to market. Trade journals are filling up with CBD advertising and it seems as if a new CBD company sprouts up every day. Yet, most massage therapists aren’t even sure they can legally use CBD. It’s a conundrum, and CBD is not going away anytime soon. Therapists are going to have ever-increasing opportunities to explore CBD in their massage work as clients start asking for it more. Here’s what you need to know.

Cannabis—a flowering plant (Cannabis sativa L.) that has been used for fiber, food, and medicine for the past 12,000 years.
Hemp—cannabis plants with 0.3 percent or less tetrahydrocannabinol (THC).
Marijuana—cannabis plants with more than 0.3 percent THC.
CBD (cannabidiol)—a naturally occurring compound found in the resinous flower of the cannabis plant. Generally assumed to be safe and nonaddictive, CBD is one of more than a hundred phytocannabinoids in cannabis. To be classified as CBD and sold legally within the states that allow it, and across state lines, it must not have more than 0.3 percent THC within its formula.
THC (tetrahydrocannabinol) —another phytocannabinoid that comes from the cannabis flower; it is the psychoactive compound in cannabis that gives users a “high.” Products that contain more than 0.3 percent THC must be sold in a marijuana dispensary, and cannot be sold online.

Let’s Start with Some Physiology

To understand how CBD works, it’s important to start with the human endocannabinoid system, often called the “master regulator.” The role of this recently identified system, in simplest terms, is to maintain homeostasis in the body. When there is stress or trauma, for example, our endocannabinoid system kicks in and, through its regulation of various body systems, brings us back to a state of balance. This system is also responsible for everything from maintaining healthy bone density2 to controlling immune cell function.3 It keeps us on an even keel, in both literal and figurative terms.
Within the body’s endocannabinoid system, there are signaling molecules (neurotransmitters) called endocannabinoids, as well as endocannabinoid receptors and the enzymes that process the endocannabinoids. According to Martin Lee, cofounder and director of Project CBD (a nonprofit that keeps its finger on the pulse of the CBD industry), the endocannabinoid system is the reason why cannabis has an effect.
It’s also the system that modulates how we experience pain, stress, hunger, sleep, mood, metabolism, memory retention, and much more.4
This endocannabinoid system has only recently been discovered (the first endocannabinoid in the body was identified in 1992), and only because scientists were looking to find out more about the effects of tetrahydrocannabinol (THC)—marijuana’s psychoactive compound, which is also a cannabinoid. The scientists’ reverse engineering on THC eventually brought about the discovery of receptors in the brain that have a pharmacological response to cannabis, and that the body, in fact, makes its own cannabinoids that act much the same as those cannabinoids that come from the cannabis plant (namely CBD and THC). With the discovery that we each have our own unique molecular signaling system that controls how we experience pain and stress, and that this system responds positively to cannabinoids of all kinds, it grew to reason that cannabinoids from the cannabis plant would have similar effects on us. Some explain it by saying the receptors have a keyhole that both endocannabinoids and cannabinoids fit into.
It is important to understand what  the endocannabinoid system comprises and what we suspect it does. Let’s look at what we call “runner’s high,” for example. This is the result of anandamide, an endocannabinoid the brain produces that is released into the body. This triggers the release of dopamine, serotonin, and the fatty acid amide hydrolase (FAAH) enzyme, which breaks down the anandamide to bring the system back to homeostasis.
Think of the endocannabinoid system as a symphony conductor or even an air traffic controller—it cues other systems to perform. And now, researchers are finally able to study this complex system in greater detail than ever before with the passage of the Agriculture Improvement Act of 2018, also known as the Farm Bill, which legalized the growth and sale of hemp and opened the doorway for advanced research opportunities into cannabis.
Now entering on center stage—CBD.

The New Kid on the Block

Until recently, not much attention was given to CBD. Its current popularity and acceptance brewed only over the past couple of years. A few factors helped create a favorable landscape for the conversation:
1. The media began running mainstream stories about CBD helping children with seizure disorders such as epilepsy.5
2. CNN’s Chief Medical Correspondent Sanjay Gupta, MD, did a four-part series detailing what he learned about cannabis and why he is now an advocate of its medicinal properties, and, in particular, CBD.6
3. The opioid epidemic opened the door wider to a public conversation on cannabis. As we look toward finding answers to address the opioid crisis, CBD has offered hopeful alternatives.
4. In June 2018, the Food and Drug Administration (FDA) approved a pharmaceutical CBD—an epilepsy medication named Epidiolex. Prior to that, all cannabis and its parts were considered an illegal Schedule 1 substance by the federal government.
5. The passage of the Farm Bill opened the door for hemp farming and CBD production, also creating opportunities for cannabis research.
Now that the FDA has de-scheduled CBD, we see it everywhere. Are you ready to offer it in your practice?

The Benefits of CBD

CBD, the second most prevalent of the cannabis plant’s active ingredients, must have a THC content of no more than 0.3 percent to maintain its hemp-derived CBD status, which is what is legally sold and used in most spas and massage clinics.
Outside the over-the-top hype that has some CBD products “curing” everything that ails you, there are several anecdotal benefits to note about CBD.
CBD is particularly well suited for:
• Reducing pain and inflammation7
• Reducing or eliminating seizures8
• Fighting the growth of tumor and cancer cells9
• Treating anxiety10   
• Managing mental illness as an antipsychotic agent11
• Reducing muscle spasms and spasms of the small intestines12
• Protecting the nervous system—managing dementia and Parkinson’s disease13
• Use with THC in autism and poststroke care14
• Reducing the undesirable effects of THC, such as inebriation, sedation, and racing heart15
CBD also appears to help maintain a healthy balance of calcium in nerve cells, which wards off the electrical overloads and damage that happen during seizures. The theory of using CBD is to support the endocannabinoid system and promote homeostasis.16
Trista Okel, of Empower Bodycare in Oregon, says, “CBD is also an antinociceptive, which means it helps reduce the nervous system’s response to painful stimuli.” And pain reduction is certainly one of the main selling points for using CBD.
In addition to reducing pain and inflammation, CBD has more subtle effects. CBD users may feel an increased sense of calm, diminished anxiety, improved mood, relaxation, and sometimes a mild “loosening” of the muscles.

CBD Side Effects and Contraindications

Despite all its benefits, there are possible side effects, drug interactions, and cautions to be aware of when using CBD. For example, CBD can inhibit the activity of some liver enzymes that are responsible for metabolizing pharmaceutical drugs. High doses of CBD can temporarily neutralize these liver enzymes, which affects the way the drugs are used in the body; eating a grapefruit while taking certain statin drugs has a similar effect. To be safe, clients and therapists currently taking any pharmaceutical drugs should speak to their pharmacist or health-care provider to discuss any possible complications before using CBD.  
Potential side effects of CBD include:
• Dry mouth
• Temporarily lowered blood pressure
• Lightheadedness or dizziness (caused by the change in blood pressure)
• Nausea (some people have found that ingesting large amounts of CBD can cause GI discomfort; suspicions are that it’s not the CBD causing the nausea, but other ingredients in the product being ingested)
• Sleepiness or drowsiness
The contraindications for using CBD would depend on whether a product is transdermal. If a topical CBD product does not have transdermal properties, the contraindications would be the same as with any topical product: avoid using on an open wound or rash. If a product is transdermal, the potential side effect of a drug interaction suggests that the client speak with a doctor prior to using CBD on a regular basis.There has been no scientific data definitively stating danger or safety when using CBD topicals on pregnant and lactating women, either to the mother, child, or fetus, but extreme caution and open discussion with your clients is recommended.
“CBD is intrinsically safe,” Lee from Project CBD says. “Cannabis is a very safe herb, so massage therapists and clients shouldn’t have any problems using CBD. It’s very reasonable that it should safely augment massage.”

How Do CBD Compounds Penetrate the Skin?

“There are many layers in our skin,” says Emma Chasen of Eminent Consulting in Portland, Oregon, a cannabis consulting business that offers educational training programs for cannabis industry professionals. “When we apply substances topically, compounds penetrate the outer layer of the skin and then permeate from one layer to another. The rate and efficiency at which the compounds permeate layers of the skin are dependent on their fat solubility and size. The lower the molecular weight and the higher the fat solubility, the easier time that compound will have penetrating the skin into the bloodstream. CBD has a relatively high molecular weight and is therefore unlikely to penetrate into the bloodstream. This means cannabidiol cannot travel through the bloodstream and will not make its way to the CB1 receptors in our brain. The CB1 receptors modulate psychotropic activity.”
So, if the cannabinoids can’t make their way into the bloodstream, how do the compounds cause an effect? “We have many receptors in our skin that cannabinoids interact with to initiate signaling pathways,” Chasen says. “Most of these receptors modulate pain and inflammation in the skin. Examples of these receptors are TRPA1, TRPM8, and TRPV-1 receptors. These receptors are found all over the body (including the skin) and cannabinoids interact with them in different ways to promote healing. There are also many other ways cannabinoids can induce a physiological experience by interacting with different enzymes and protein channels. This is why CBD products applied topically can be so helpful in relieving pain and reducing inflammation.”

Topical CBD Products

When topical CBD products hit the national scene a few years ago, all the products had significant amounts of other ingredients that manufacturers advertised as “proprietary” combinations. Many products use ingredients like emu oil, dimethyl sulfoxide (DMSO), and lidocaine to name a few. These synthetic and natural ingredients have transdermal properties, meaning the manufacturers are intentionally creating topical CBD products that will be absorbed into the body, not only down to the muscles and joints, but also into the bloodstream.  
Chris Diaz, CEO and cofounder of Lacuna Botanicals in Colorado, best explains why massage therapists shouldn’t be concerned about using a transdermal CBD product. “Consider the use of aromatherapy by massage therapists,” Diaz says. “This is a widely used therapy. It is the delivery of legal botanicals/essential oils through the mucous membranes in the nose. This is a more direct delivery mechanism than any topical delivery. I don’t think aromatherapy should be out of scope for LMTs, nor do I feel CBD—which is also a legal botanical—should be out of scope for an LMT.
“CBD has been widely recognized by organizations such as the World Health Organization (WHO) and the World Anti-Doping Association (WADA), which have taken CBD specifically off the banned list and acknowledged its benefits for Olympic athletes for pain and inflammation. WADA is very selective on what it allows—CBD is specifically allowed; THC is not.”17
Even with a transdermal product, “the odds of [CBD topical use] triggering a drug test are pretty negligible,” says Jeff Chen, MD, director of the UCLA Cannabis Research Initiative, who told the audience at the American Spa CBD Summit in August 2019 that the chances were “slim to none” that THC from these topicals would get picked up in a drug screening. Yet, he also said when it comes to things like the right dosage or the right carrier for CBD, “I can’t give you those answers yet.” That is why some government workers (and others whose jobs require frequent testing) have been advised to avoid CBD altogether until there are more definitive answers in this newly burgeoning industry.
What is the stance of national industry groups on the subject? According to Debra Persinger with the Federation of State Massage Therapy Boards (FSMTB), when it comes to transdermal products and the use of CBD in massage, “The FSMTB supports public protection and that includes protecting the licensed professionals. While a client may knowingly request the use of lubricants that are absorbed into the body, the therapist cannot be unwittingly exposed to the effects of the ingredients accumulating over multiple clients each day. The safety of the therapist is equally as important as the safety of the client.”
What does this mean? It means we don’t have enough research out there, so tread carefully and protect yourself.

Some Closing Thoughts

There is new information on this topic every day and new products are hitting the market at a rapid pace. If you choose to offer CBD-infused massage to your clients, and have ensured it’s within your scope of practice, make sure you stay on top of the latest research. Both client and therapist need to understand how and why these products work. And even though experts don’t always agree, what we know for sure is that CBD is not going away. The public’s rapid adoption and demand for this product will ultimately bring great therapeutic rewards for our clients.


M&B: How much CBD is recommended for effective spot treatment versus a full-body massage?
Julie Crispin: I have asked this question of many CBD topical producers. Lack of clinical data gives us little to no specific guidelines. Anecdotally, both producers and practitioners lean in the direction of about 25 milligrams of CBD for full-body massage. Labels can be confusing and misleading. A product may say 500 milligrams of CBD on its label, but have 16 ounces of lotion. Figuring out the math of how much CBD is in a “serving” can be difficult, so make certain you understand the labels and the manufacturers’ recommendations. There are some products that are meant for full-body massage, and others that are formulated for spot treatments.

M&B: Some consumers like to include hot stones in their full-body therapeutic massages with CBD. Do you think the heat has an effect on the cannabidiol?
JC: According to industry expert Sally Alworth of Luminous Botanicals, CBD’s boiling point is between 320 and 356 degrees Fahrenheit, well above the temperature you would heat a stone for a massage, so there is little risk of altering or destroying CBD during hot stone massage. “While I have never seen any specific data on increased penetration of CBD with heat, there is a body of research related to how changes in skin temperature can increase the absorption of some transdermal and topical medications, a concern for doctors prescribing medications in sustained-release patches. Therefore, it seems like a reasonable theory that the increased blood flow and opening of the pores caused during hot stone massage might increase the penetration of CBD and other cannabinoids,” Alworth says.

M&B: What should I look for when choosing a product line?
JC: Certificate of Analyses (COAs). The manufacturer should easily provide access to independent third-party lab testing results. (Be wary—many manufacturers have their own labs.) Look for a QR code on the product or a link to the company website with up-to-date, independent third-party lab results. I strongly suggest you choose CBD products sourced with locally grown hemp—North America rather than foreign sources. Personally, I want a product as natural and environmentally sourced as possible, and ingredient transparency is imperative.

We asked Chris Diaz, cofounder of Lacuna Botanicals in Colorado, which manufactures CBD products for the spa and bodywork community, to answer the questions most important to massage therapists.

M&B: Will my clients or I get high using CBD?
Chris Diaz: Pulling pure CBD isolate out of either hemp or marijuana is chemically the same exact thing. The distinction is relevant, however, when you’re talking full-spectrum oil. This is because hemp-derived full-spectrum oil will have low THC, while marijuana-derived full-spectrum oil will be quite high in THC. If you add hemp-derived full-spectrum oil to a consumer product, it won’t make you high. If you add marijuana-derived full-spectrum oil into a consumer product, it won’t make you high but it could deliver slight amounts of THC into your system. The majority of products out there use full-spectrum oil rather than isolate, so this distinction is relevant.

M&B: Can I give CBD massages legally?
CD: First, check your state regulations, and make sure your insurance covers this work. CBD with 0.3 percent or less THC was made federally legal by the 2018 Farm Bill, and was, in fact, even made legal by the 2014 Farm Bill. The problem with the 2014 Farm Bill was that hemp was still considered a controlled substance by the Drug Enforcement Administration (DEA)—it was a Schedule 1 drug along with heroin and methamphetamines. This caused a lot of gray area because you had conflicting federal laws. The 2018 Farm Bill eliminated this problem by removing hemp with under 0.3 percent THC from the controlled substances list. So, at a federal level, there is no gray area anymore. It is straight up legal and no different than other crops like corn.
Yet, it is possible for some states to have state-level legislation that makes all cannabis (including hemp) illegal in their specific state.   
So, what does this mean for legality in a state with outdated laws on the books? It means that just like with the 2014 Farm Bill, there is still gray area in a few states.
M&B: Can CBD with less than 0.3 percent THC create a positive drug test in clients? What about in MTs who might give 4–5 CBD massages a day?
CD: This is a big one. It goes back to that full-spectrum versus isolate aspect. If you are using a product that is based on full-spectrum oil, then it is definitely possible to test positive for THC on a drug test—especially for someone like an MT who is using it in 4–5 massages a day.
Isolate is different, however. It is the pure form of CBD that has been “isolated” from everything else in full-spectrum oil, including THC. Think of it like a glass of sweetened iced tea. If you were to let all the water evaporate, you’d be left with tea particulates and sugar. It would probably look like brown sugar. If you took that and separated out all the tea particulates, you’d be left with pure white sugar. This is similar to pure CBD isolate. This is what we use in our formulations at Lacuna.

Cannabinoids: The chemical compounds that act on the body’s cannabinoid receptors as part of the endocannabinoid system.

Endocannabinoids: Chemical compounds produced naturally in the body.
Phytocannabinoids: Any of the 100-plus cannabinoids naturally derived from the cannabis plant.
Synthetic cannabinoids: Cannabinoids that are artificially produced.

Full-Spectrum CBD: In full-spectrum CBD products, cannabis plants are processed to retain all the elements of the plant—the cannabinoids, terpenes, flavonoids, and trace amounts of THC. If a product advertises itself as full spectrum, remember there is no such thing as THC-free full spectrum.  

Broad-Spectrum CBD: A product where the THC is eliminated from the spectrum, but everything else is left behind.

CBD Isolate: This is what remains when all plant material except CBD is removed in the processing of cannabis. Considered the purest form of CBD, users like the isolate’s quality control factor and lack of THC.

Transdermal: Products that push past the epidermis and dermis to deliver ingredients deeper than topical surface application into the circulatory system and eventually to cross the blood-brain barrier.
Entourage Effect: Cannabinoids, terpenes, and flavonoids from a plant naturally work synergistically together as a whole better than as individual components. Some CBD products claim that whole-plant ingredients are superior because of this natural entourage effect. Other products mimic the entourage effect by adding in complementary ingredients and essential oils. There is no scientific data to date, but anecdotal evidence strongly suggests the entourage effect is a factor in plant medicine.

ABMP’s CBD Insurance Coverage

As the use of cannabidiol (CBD) for therapeutic purposes becomes more common, many ABMP members have raised questions about the legal use of CBD-infused massage products. (Remember, scope of practice limits you to the application of CBD creams, oils, salves, etc.—not edibles, supplements, tinctures, vapors, or medicines.)
Most massage-oriented CBD products are derived from hemp, and, as a result, have minimal—less than 0.3 percent—THC.
Whether a state will allow massage therapists to use CBD is up to the interpretation of the massage regulatory board in that state, and the speed at which federal, state, and massage board regulations catch up to one another in the aftermath of the passage of the 2018 Farm Bill. For example, some states have specific policies and rules regarding the use of CBD, with some outright saying they cannot be used in the practice of massage therapy. Most others will not give guidance on the issue at all.
The ABMP Government Relations team encourages you to be aware of your state’s position regarding CBD, as well as the massage therapy board’s position, if they have one, before using CBD in your practice.
The other issue members face regarding the use of CBD is whether they will be covered by their liability insurance if a client is injured while CBD is being used. For ABMP members:
• The legality of the use of CBD-infused massage products is determined at the state level. Your state massage board/regulatory agency can confirm whether the use of CBD products is within the scope of practice for your state.
• As a reminder, the liability insurance provided as a benefit of ABMP membership requires adherence to state regulations as a condition for coverage. Any products that exceed 0.3 percent THC, or that could make a practitioner or client “high,” are considered intoxicants and not covered by the liability insurance provided as a benefit of ABMP membership. To be covered, the THC products you use also must be explicitly authorized by your state licensing board.

Industrial Hemp?

Industrial hemp has many uses, including being grown for environmental remediation—meaning it is used to clean up industrial waste. Industrial hemp is a bioaccumulator, meaning it absorbs chemicals and heavy metals from the soil. As is often the case, after a crop has been used for soil remediation, it can be sold to manufacturers who reuse it for another purpose altogether—clothes, lotions, supplements, and extracts. Little oversight exists over importing industrial hemp from other countries and, as a result, industrial hemp-derived CBD products could contain all kinds of toxins and/or pesticides.
With the 2018 Farm Bill, hemp was legalized and removed from the definition of marijuana under the Controlled Substances Act. The Farm Bill provides a detailed framework for the cultivation of hemp, and gives the US Department of Agriculture regulatory authority over hemp cultivation at the federal level. In turn, states have the option to maintain primary regulatory authority over the crop cultivated within their borders by submitting a plan to the USDA. Most states have introduced (and adopted) bills that would authorize the commercial production of hemp within their borders.

A Guide to Incorporating CBD Into Your Practice

• Do your research and educate yourself and your clients about CBD.
• Find the product that is right for you and your clients. There may be more than one product that works for different situations.
• Confirm whether a product is transdermal. If it is, decide whether you should use gloves. If a product is transdermal—and full spectrum—there is the chance that some THC could show up in a drug test.
• Keep your marketing language rooted in science-based evidence and don’t make unsubstantiated health claims.
• Check your state and local regulations regarding the use of CBD in your practice and/or your ability to sell CBD products.
• If CBD is named in your billing or booking services, it’s important to check with your bank and your vendors to ensure you won’t lose their services by providing CBD in your business. Local credit unions are good alternatives.
• Confirm that your liability insurance covers you for using CBD.
• Obtain written consent from your client if you choose to use CBD. (Find a sample CBD waiver in this issue’s digital edition.)
• Find your price. Some add CBD to massage for a $10 upcharge, while some spas charge up to $200 for a CBD spa service.

A Business Model: LoDo Massage

If you were to book therapeutic massage at one of the two LoDo Massage locations in Colorado, you would get what’s called the Mile High Massage—a massage administered with CBD lotion or oil. In fact, every massage on LoDo’s service menu comes with CBD, if you want it. And most clients do!
When LoDo Massage first started offering CBD massages to clients in 2014, owner Ed Rich says the client base tripled. When the local newspaper wrote about LoDo’s Mile High Massage service, “It exploded,” Rich says. “From that day forward, business has never been slow.” He says while a few clients opt out of having a CBD lubricant used during the massage, most want it included in their service to address pain and other health issues.
A frontrunner in offering cannabis massages in Colorado, Rich says his company’s national seated massage business will test the waters in taking CBD on the road. “With 4,000 [seated massage business] accounts nationwide, I am in discussions on bringing CBD into the workplace.” With the greater acceptance of CBD and its huge growth, Rich says the time is ripe for CBD and corporate massage. His goal? “Being the first company nationally to bring CBD massage inside corporations—that’s really where I’m heading right now.”

Massage therapist Matthew Behr first heard about cannabis-infused analgesics in 2013 when a friend offered him an oil she had purchased from a medical dispensary. “I began incorporating it into my private practice when I first opened in 2014 because I liked working with it so much, and recreational legalization made that possible here in Colorado,” he says. “Locals were very excited to try CBD in their sessions from the beginning, while people from out of town tended to have a lot more questions about it. These days, it seems everyone is eager to try it.”
For an upcharge of $20, Behr says he incorporates CBD into a full-body massage or applies it to specific areas of pain and tension. “Objectively, I can feel the (client’s) tissues relax with much more ease as the topical soaks in, and I am able to really get more work done. People leave feeling completely blissed out and report being totally pain-free.”
And, as a therapist, he reaps the benefits of CBD as well. “I used to have problems with my thumbs aching and feeling like they were going to give out after a long day of massage.” Behr says there is a definite correlation between his CBD exposure and the diminished pain. “I have been pain-free for years now. My thumbs and wrists are my livelihood and I’m in this for the long haul, so it’s vital for me to continue to apply the topical within, as well as out of, sessions.”


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Julie Crispin has been a licensed massage therapist in Oregon since 2007. She has a thriving private practice and teaches CE classes nationally on the subject of CBD and massage. She has served in several volunteer positions in the massage profession and is currently on the Oregon Board Massage Therapists Education Advisory Committee. For more information about her work, visit www.massagetopicals.com.
Karrie Osborn is senior editor at Associated Bodywork & Massage Professionals.