According to the American Chronic Pain Association, fibromyalgia may affect as many as 12 million people in the United States. It’s a painful and potentially debilitating condition with no known cause and no cure. The drug companies of the world are always working hard to discover the next breakthrough for people with fibromyalgia. However, the current drugs available for treating the condition are often woefully ineffective and may introduce many unwanted side effects of their own. You’re here because you want to know if taking cannabis oil for fibromyalgia can provide some therapeutic benefits. This article will summarize the information available about hemp oil for fibromyalgia and help you make the right decision for your health.
This article is not medical advice. CBD oil is not an FDA-approved medication and is not intended to diagnose, treat or cure any disease.
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CBD for Fibromyalgia: Our Top Pick
This article’s goal is to provide the most comprehensive overview of the effects of CBD on fibromyalgia available anywhere. When you’re done reading, you should have a very good idea of whether CBD is the right treatment option for you. You may not have time to read the full article, though, and might simply be looking for an actionable recommendation that helps you along your way.
Our top recommended CBD oil for fibromyalgia is BioMD+. We love BioMD+ not only for the high quality of their hemp extract, but also for the fact that the company enhances its oils with additional terpenes that may help to amplify the benefits of CBD. BioMD+ offers a CBD oil with terpenes specifically selected to enhance CBD’s anti-inflammatory effects, and that product may be helpful to those suffering from fibromyalgia.
There are many, many CBD brands in the world, and what most of them have in common is a lack of any kind of satisfaction guarantee. If you don’t like your experience with most CBD brands, you’re out of luck. BioMD+ has made itself a prominent exception by offering a money-back guarantee. If you don’t experience a benefit from using BioMD+ CBD, you can simply send the product back.
What Is Fibromyalgia?
Fibromyalgia is a disorder that causes widespread pain in the muscles, connective tissue and bones. Although fibromyalgia seems to typically set in during adulthood, researchers haven’t pinpointed a single cause. It’s also a difficult condition to diagnose. Arriving at a diagnosis of fibromyalgia usually requires ruling out several other more common disorders first. Scientists believe that the condition could be the result of oversensitive nerve cells; people with fibromyalgia have very low pain thresholds and may experience pain even when touched.
The most common symptoms of fibromyalgia include:
- Constant pain that occurs in both the upper and lower halves – and on both sides – of the body; sufferers may describe sensations such as dull aches and tingling along with twitching and spasms of the muscles
- Tiredness, possibly due to low sleep quality; patients with fibromyalgia often experience sleep interruptions due to pain or have comorbid sleep disorders
- Poor mental acuity that manifests itself as forgetfulness, inability to concentrate or difficulty performing multiple tasks simultaneously
Fibromyalgia doesn’t cause bodily deterioration or death, but it has no known cure. Most people with fibromyalgia do not report improvements with time. Since researchers do not know what causes fibromyalgia, doctors tend to focus their treatment efforts on helping patients manage their symptoms.
Risk Factors for Fibromyalgia
Although scientists have yet to pinpoint the cause of fibromyalgia, they do know that several risk factors can contribute to its development. Those risk factors include:
- Family history. If you have a relative with fibromyalgia, you are more likely to develop the condition yourself.
- Trauma. Some people develop fibromyalgia after experiencing traumatic events such as head injuries and car accidents.
- Psychological stress. Extreme worry and anxiety may trigger the onset of fibromyalgia.
- Mental disorders. There appears to be a strong link between fibromyalgia and certain mental disorders such as clinical depression and bipolar disorder.
- Sleep disorders. A study found that people can develop fibromyalgia-like symptoms after repeated interruptions of REM sleep.
- Lifestyle choices. Being overweight, smoking and exercising too infrequently can all potentially contribute to the onset of fibromyalgia.
- Gender. Most fibromyalgia sufferers are women.
Perhaps because it comes from a similar genetic abnormality or because it affects a similar area of the neural pathway, fibromyalgia is often comorbid with other disorders. Those disorders include rheumatoid arthritis, osteoarthritis, multiple sclerosis, lupus, irritable bowel syndrome, immune system disorders, migraine headaches and muscular or joint disorders. In some cases, comorbid disorders may go undiagnosed because sufferers assume the symptoms of those disorders are fibromyalgia symptoms.
Why Is Fibromyalgia So Difficult to Treat?
Fibromyalgia is difficult to treat because researchers haven’t identified a single underlying cause. In addition, there appear to be several different types of fibromyalgia – and each of those types may respond to a different treatment regimen or medication type. The classifications that have been proposed are:
- Fibromyalgia without another mental disorder
- Fibromyalgia that causes clinical depression
- Fibromyalgia and depression that appear independently of one another
- Fibromyalgia appearing due to a somatic disorder
Due to the lack of understanding about its pathogenesis, there is no single accepted treatment for fibromyalgia. Some patients respond well to certain treatments, and other patients go through several different treatment regimens without success.
Some of the most common treatments proposed for fibromyalgia include:
- Gabapentinoids such as pregabalin. These drugs block voltage-dependent calcium channels and are used to treat neuropathic pain along with other conditions such as anxiety disorders and restless legs syndrome.
- Serotonin-norepinephrine reuptake inhibitors such as duloxetine. Doctors prescribe these drugs for treating neuropathic pain, depression, anxiety and urinary incontinence.
- Tricyclic antidepressants such as amitriptyline. These drugs increase serotonin and may also help to treat major depression and migraines.
- Anticonvulsant medications such as gabapentin. These drugs are also used to reduce seizures. Unfortunately, more than half of those who take gabapentin to treat pain from fibromyalgia report unwanted side effects.
- Opioids such as tramadol. Opioids are used to treat many types of pain. Doctors typically recommend against using opioids to treat lifelong pain conditions such as fibromyalgia, though; strong opioids are more likely to cause dependency, and the pain relief derived from weak opioids is often minimal.
- Over-the-counter pain medications such as ibuprofen and acetaminophen. Although these medications tend to have limited effectiveness for relieving fibromyalgia pain, they also don’t cause dependency as opioids can.
- Cognitive-behavioral therapy may help those with fibromyalgia live fuller lives by teaching them to cope with the pain.
- Exercise can greatly improve outcomes among those with fibromyalgia by strengthening the muscles and lessening fatigue.
As you can see from the list above, doctors’ treatment plans for fibromyalgia may vary greatly depending on the needs of individual patients and the outcomes that those doctors have observed in the past. It isn’t yet possible to treat the root cause of fibromyalgia because we don’t know what the root cause is.
Different chemical compounds affect the body in different ways. Some merely reduce pain; others alter the brain’s chemistry. Some people experience good results and no side effects when taking prescription medications. Others find that the side effects are far worse than the symptoms of the disease. In many cases, prescription medications can cause dependency and addiction.
What Is CBD?
Cannabidiol (CBD) is a non-psychoactive compound taken from the cannabis plant. Like tetrahydrocannabinol (THC), CBD is a cannabinoid that interacts with the body’s endocannabinoid system. Unlike THC, CBD will not get you high.
Cannabis is a complex plant that comes in two different classifications. When it’s bred for its THC content and used recreationally or medicinally, it’s called marijuana. When it’s bred for its fibers and seeds, it’s called industrial hemp. Industrial hemp has almost all of the THC bred out of it. Federal law permits farmers to grow hemp if its THC content is no more than 0.3 percent. Even if you smoke it, you will not get high.
While industrial hemp contains almost no THC, it is rich in CBD. As more nations and states have enacted medical marijuana laws, researchers have increased their efforts to understand what the compounds in cannabis are and how they affect the body. They’ve discovered that even without the euphoric properties of THC, CBD oil may provide an enormous variety of health benefits. People are using CBD to reduce inflammation, improve sleep quality, combat anxiety and more.
In the United States, the FDA has been slow to recognize the therapeutic potential of CBD. Studies have proven, though, that CBD can benefit those who suffer from certain rare seizure disorders. The FDA has approved Epidiolex – a CBD-based prescription drug – as a treatment for those who suffer from Dravet syndrome and Lennox-Gastaut syndrome. Although studies evaluating the effectiveness of CBD for treating other health conditions have produced promising results, many of those studies have either lacked placebo control or used animals as test subjects. In other words, anecdotal reports provide much of the “evidence” of CBD’s ability to relieve fibromyalgia symptoms.
What Is the Endocannabinoid System?
The endocannabinoid system is one of the body’s intercellular messaging systems. The body manufactures its own cannabinoids – endocannabinoids – that transmit messages between cells. The cells receive those messages via cannabinoid receptors. The endocannabinoid system regulates bodily processes such as pregnancy, appetite, mood and pain response. Cannabinoids from external sources – such as cannabis – interact with the endocannabinoid system, either by stimulating the cannabinoid receptors or by binding to the receptors to reduce the transmission of other messages. Some doctors have hypothesized that certain health conditions may actually result from endocannabinoid system deficiencies. It is possible that cannabis has medicinal value for some people because it helps to correct those deficiencies.
Scientific Studies About CBD and Fibromyalgia
Since fibromyalgia is poorly controlled by existing prescription medications, researchers have a strong incentive to find new strategies for treating the condition. As a result, there have been several studies evaluating the effectiveness of CBD and cannabis as fibromyalgia treatments along with their ability to relieve neuropathic pain in general. We’ll cite those studies here to serve as a basis for your further research.
- In 2018, Pain Research and Treatment published the results of an anonymous online survey of 383 fibromyalgia patients in Israel. Of those who responded, 84 percent reported using cannabis to treat their conditions. Among those who used cannabis, 94 percent experienced pain relief and 93 percent reported improved sleep.
- In 2011, PLOS One published the results of a survey examining 56 fibromyalgia patients. Half of those patients used cannabis to treat their fibromyalgia, and the other half did not. Otherwise, the two groups were similar. Those who used cannabis reported improved mood, reduced pain and higher sleep quality.
- In 2016, the Cochrane Library published a review of studies examining the effectiveness of the synthetic cannabinoid nabilone in treating fibromyalgia. The study found no evidence that nabilone is an effective fibromyalgia medication. Since many people have successfully used plant-based cannabis to treat the condition, it seems likely that the plant itself is responsible for the relief those patients experienced and that no synthetic substitute can duplicate the plant’s effects.
- In 2018, the Cleveland Clinic Journal of Medicine published a review in which researchers examined the effectiveness of cannabis in the treatment of pain that is otherwise difficult to manage. The study concluded that cannabis may be an effective treatment for chronic pain conditions that respond poorly to prescription medications.
- In 2019, Pain published a study evaluating the effectiveness of CBD in treating an animal model of neuropathic pain. CBD administration reduced pain and anxiety in the test subjects. However, the study noted that the full effect of CBD treatment wasn’t instant. Peak results were achieved after administering CBD to the animals for one week. The study’s result suggests that repeated CBD dosage is necessary for effective treatment of chronic neuropathic pain.
- In 2007, the European Journal of Pharmacology published the results of a study in which animals were given CBD orally each day as a treatment for neuropathic and inflammatory pain models. The study concluded that CBD shows potential as a treatment for chronic pain conditions.
How CBD May Help to Relieve Fibromyalgia Symptoms
Wait a Week to Gauge CBD’s Effect on Fibromyalgia Pain
When you consider whether taking CBD for fibromyalgia is the right decision for you, the first thing you should note is that not all patients report relief from fibromyalgia after taking CBD. Just as prescription medications do not work for everyone, there is a chance that you will not experience relief from using CBD. As noted above, though, you should wait at least one week before making your decision because that’s about how long it’ll take for you to experience the full effects.
CBD May Reduce Inflammation
Several studies have shown CBD to be a powerful anti-inflammatory agent. In one study, topical administration of CBD gel reduced inflammation in rats with an animal model of arthritis. In another study, CBD prevented brain damage in an animal model of stroke. Both studies used very high CBD doses to achieve their results. Nevertheless, the results clearly show CBD’s anti-inflammatory and neuroprotective effects.
CBD May Disrupt the Body’s Pain Messaging
As we mentioned above, the endocannabinoid system is one of the pathways through which the body transmits pain messages. Although CBD does influence one of the tangible markers of pain – inflammation – it may also provide pain relief because it disrupts the body’s own pain messaging system. You can only feel pain if your nervous system tells you that you’re feeling pain.
CBD May Correct Endocannabinoid Deficiencies
Above, we mentioned the hypothesis that endocannabinoid system deficiency is the root cause of certain diseases. That hypothesis was proposed in an article that appeared in the journal Cannabis and Cannabinoid Research in 2016. According to the article, treatment-resistant conditions such as fibromyalgia, migraine and irritable bowel syndrome can all potentially be traced back to endocannabinoid system deficiency. This hypothesis echoed an earlier hypothesis proposed in Neuroendocrinology Letters in 2008. It is possible that CBD relieves fibromyalgia symptoms for some patients because it corrects that deficiency.
CBD vs. Medical Marijuana for Fibromyalgia
You may have noticed that many of the studies referenced above discuss the effectiveness of medical marijuana – not CBD itself – in fighting neuropathic pain. While CBD may relieve pain in subtle ways by reducing inflammation or disrupting the body’s ability to send pain messages, the THC in marijuana is a powerful analgesic in its own right. It’s possible that THC and CBD may work synergistically by fighting fibromyalgia pain in different ways. In states with medical marijuana programs, it’s likely that many doctors would be willing to prescribe cannabis to fibromyalgia patients – especially if those patients haven’t responded to traditional prescription medications.
As we mentioned above, fibromyalgia patients consistently report in surveys that medical marijuana eases their symptoms. However, marijuana also has some side effects that you may find undesirable. Using marijuana may impair your judgement. It may make it difficult for you to go about your daily business because you feel overly medicated or “high.” Overconsumption of strong marijuana strains can lead to a sleepy sensation that cannabis users call “couch lock.” Acute marijuana use can also cause paranoia and anxiety.
CBD alone doesn’t act on the body in the same way as marijuana. If both treatment options are available to you, it may be wise to try both CBD and marijuana and determine which is more effective in providing relief for your condition. If CBD works for you, you may find that you prefer it over marijuana since it provides relief without the high. Most people experience no side effects from using CBD. A few people experience mild side effects such as dizziness, drowsiness and dry mouth.
Ways to Take CBD Oil for Fibromyalgia Pain
The three most common ways to take CBD for fibromyalgia are orally, sublingually and by vaping. We’ll discuss the pros and cons of those three methods.
- Taking CBD sublingually involves holding a dropper of CBD oil under the tongue for up to a minute before swallowing it. The first benefit of using CBD oil sublingually is that it provides both fast-acting and long-lasting effects. When you hold the oil under your tongue, the tissues in your mouth begin to absorb the CBD immediately. The digestive system processes the remaining CBD, and that can take several hours. The second benefit of this administration method is that CBD oil is the most cost-effective CBD product in terms of the money spent per milligram of CBD.
- Taking CBD orally involves eating CBD-infused food products such as gummies. CBD gummies provide consistent CBD dosages; you always know how much CBD you’re consuming because the package clearly states how much CBD each candy contains. The digestive system, however, can be slow to process CBD. After you eat a candy, it may be up to two hours before you begin to experience relief. CBD gummies are also significantly more expensive than CBD oil.
- Vaping CBD involves putting CBD oil or CBD-infused vape juice into a vape pen that heats the substance until it turns to vapor. When you inhale the vapor, you absorb the CBD through your lungs. Vaping is an extremely fast way to get CBD into your system, so it’s a perfect way to use CBD for sudden acute pain. Vaping CBD, however, may not give you the same long-lasting effect that you would get from using CBD orally or sublingually. If you use a vaping tank designed for oils, though, you can vape the same CBD oil that you use sublingually.
CBD Dosage for Fibromyalgia
As we mentioned above, researchers who have studied the effects of CBD on chronic pain and neuropathic pain have typically used high doses of CBD. If you find that CBD provides relief from your fibromyalgia symptoms, you’ll probably discover that a higher CBD dosage provides even more relief. It’s wise, though, to begin with a smaller dose until you gauge the effect that CBD has on your body. Check for drowsiness, dizziness and other undesirable symptoms. If you experience no negative side effects, increase your doze gradually until you find the amount of CBD that’s therapeutic for you.
Using CBD With Prescription Medication for Fibromyalgia
Although few adverse reactions from taking CBD with prescription medication have been documented, it’s still wise to talk to your doctor before beginning a CBD regimen. That’s because CBD inhibits the production of certain enzymes that the body uses to break down medications. The enzymes in question are called CYP3A4 and CYP2D6. Some of the medication classes that interact with those enzymes are benzodiazepines, calcium channel blockers, opioids, tricyclic antidepressants and selective serotonin reuptake inhibitors. Those drug classes include some of the medications that doctors commonly prescribe to fibromyalgia patients.
If CBD inhibits the production of an enzyme used to break a medication down, it could theoretically increase the concentration of that medication in your blood by causing the drug to metabolize more slowly than it normally would.
How to Choose the Best CBD Products for Fibromyalgia
All CBD products are not the same. If you’ve decided that you want to find out for yourself whether CBD can ease your fibromyalgia symptoms, you want to choose the CBD brand that gives you the best possible chance of success. These four pointers will help.
Hemp Quality is Key
One of the most important factors influencing the quality of any CBD product is the quality of the hemp extract itself. Hemp has the natural ability to draw toxins such as heavy metals, radiation and pesticides out of the soil, and those toxins can end up in the oil extracted from the plant. Before you buy a CBD product, learn as much as you can about the origin of the hemp.
Full-Spectrum CBD vs. CBD Isolate
Are you subject to random drug testing? If you are, you need to understand the difference between full-spectrum CBD oil and CBD isolate. A full-spectrum hemp extract has naturally occurring terpenes – we’ll discuss those in a moment – but it can also contain trace levels of THC. Remember, industrial hemp can contain up to 0.3 percent THC by weight. If you take enough CBD oil, the trace THC could potentially show up in a drug test even though you’ll feel no effects from it. CBD isolate, on the other hand, goes through additional purification that removes the THC and terpenes. CBD isolate should not show up on a drug test that checks for THC metabolites.
When you take CBD for any condition, it’s a good idea to start small and build up slowly until you find your therapeutic dose. Many people find, though, that their effective CBD doses for pain control are quite high. It’s a good idea to choose a brand that offers high-strength CBD oil. If you can buy high-strength CBD oils – and your bottles last longer as a result – you’ll spend less on CBD in the long run.
The Value of Terpenes
Terpenes are natural compounds that give plants their characteristic scents and flavors. As you might guess from the smell, hemp is rich in terpenes. Many of those terpenes provide benefits of their own, so it’s wise to choose a CBD oil with the natural terpenes left intact or with added terpenes selected to fight pain and inflammation. Some of the terpenes with known inflammation-reducing properties include pinene, limonene, beta-myrcene, beta-caryophyllene, linalool and alpha-humulene. Linalool, in particular, has shown potential as a treatment for fibromyalgia. In discussing CBD oil, many people mention the “entourage effect.” It’s the theory that CBD and terpenes together can provide more effective relief than either of those compounds could provide on their own.
What Other Natural Fibromyalgia Remedies Exist?
Since fibromyalgia has no known cure, all treatment options that currently exist focus on helping patients manage their symptoms. As we mentioned above, many prescription medications have side effect profiles that, for some patients, are even worse than the disease itself. It’s not surprising, then, that many people look for alternative and natural fibromyalgia remedies.
The best natural treatment regimen for fibromyalgia is one that examines the problem holistically and is cognizant of the fact that every health decision you make can potentially alleviate or aggravate your symptoms. None of these natural remedies are likely to greatly ease fibromyalgia symptoms on their own. However, they can be important parts of a complementary health plan that eliminates risk factors and helps you lead a fuller and more active life.
- Improving sleep quality: Many people with fibromyalgia report that they feel tired during the day, even when they think they’ve gotten enough sleep. That may be because the pain from fibromyalgia interrupts sleep during the REM phase. Researchers have found a possible link between disrupted REM sleep and fibromyalgia. Anything that you can do to improve sleep quality may alleviate fibromyalgia-related pain and fatigue. Avoid caffeine, alcohol, noise and devices with bright screens in the hours before bedtime. Supplements like melatonin may also help.
- Exercise: Multiple studies have shown that exercise can improve mobility and quality of life for fibromyalgia patients. It’s important not to overwork yourself, though, because an exercise program that’s too vigorous can aggravate your existing musculoskeletal pain. Your doctor can likely refer you to a physical therapist who will create an exercise program tailored to your needs.
- Stress reduction: There is a strong link between stress, anxiety and fibromyalgia. You may find, therefore, that improving your mental state can also alleviate fibromyalgia pain. That’s why some fibromyalgia patients experience benefits from cognitive-behavioral therapy. Meditation, massage and yoga may help. Consider starting a blog and writing about your experiences. Your city may also have a support group for fibromyalgia sufferers.
- Acupuncture: A 2014 systematic review published by Cochrane states that about 20 percent of fibromyalgia sufferers try acupuncture. The review suggests that acupuncture seems to alleviate pain for some with fibromyalgia. Acupuncture also appears to be safe, so there is little risk in trying it. However, there isn’t enough clinical data available to make a strong recommendation.
- Vitamin D: A comprehensive review comparing 851 fibromyalgia cases with 852 control cases appeared in the Korean Journal of Pain in 2017. The review found that those who have fibromyalgia have significantly lower vitamin D levels than those without fibromyalgia. It is possible that taking a vitamin D supplement could alleviate your symptoms.
- Low-FODMAP diet: FODMAPs are sugars and sugar alcohols that ferment in your intestines because your body can’t process them fully. Since there is a link between fibromyalgia and gastrointestinal conditions such as irritable bowel syndrome, it’s important to avoid any foods that could cause intestinal inflammation and gas. A 2016 study published in the Scandinavian Journal of Pain supports the notion that a low-FODMAP diet can ease fibromyalgia symptoms. Some of the foods that you should avoid on this diet include dairy products, beans, wheat, onions, high fructose corn syrup, processed foods, some fermented foods and anything sweetened with sugar alcohols such as xylitol and sorbitol.
- Magnesium: Some studies have shown that patients with fibromyalgia tend to have lower magnesium levels than control groups. It is therefore possible that magnesium supplementation could improve fibromyalgia symptoms. In 1995, the Journal of Rheumatology published a double-blind crossover study in which patients with fibromyalgia were given Super Malic, a proprietary blend of malic acid and magnesium. Patients observed significant reductions in pain and tenderness when given large doses of Super Malic. However, large doses of magnesium can also cause gastrointestinal upset and other side effects.
- Transcranial magnetic stimulation: A 2016 review published in Pain Practice found that transcranial magnetic stimulation – a procedure in which practitioners stimulate the brain with magnetic fields – appears to reduce pain from fibromyalgia. There is no evidence to indicate that it reduces depression in fibromyalgia patients.
- Reiki: In 2008, the National Center for Complementary and Integrative Health funded a double-blind placebo-controlled study on reiki and fibromyalgia. Reiki is a practice in which practitioners touch patients gently or hover their hands over patients to facilitate energy transfer and stimulate natural healing. Members of the reiki group received 16 treatments over a two-month period. At the end of the trial, the reiki group showed no improvements compared to the control group.
- Manual lymph drainage therapy: Manual lymphatic drainage is a form of massage that attempts to encourage the movement of lymph and speed the removal of toxins from the body. In 2009, the Journal of Manipulative and Physiological Therapeutics published a study in which researchers compared the effectiveness of lymphatic drainage therapy vs. standard massage for fibromyalgia patients. The study lacked a control group but found evidence to suggest that lymphatic drainage could be an effective complementary treatment for fibromyalgia.
- Fish oil: Although no studies exist to confirm the effectiveness of fish oil as a natural fibromyalgia remedy, many doctors do recommend fish oil and other omega-3 oils to patients as a means of reducing inflammation. In 2006, Surgical Neurology published a study in which 250 patients with neck and back pain were given 1,200 mg of omega-3 fatty acids per day. Of those patients, 60 percent said that their pain had improved, and 88 percent said that they intended to continue taking fish oil supplements.
- Ashwagandha: Ashwagandha is one of the staple herbs of ayurvedic medicine, and many doctors recommend it to fibromyalgia patients. There are no studies evaluating the effectiveness of ashwagandha as a treatment for fibromyalgia, but there are studies confirming its effectiveness as a pain reliever. In 2016, the Journal of Ayurveda and Integrative Medicine published a double-blind placebo-controlled study examining the effectiveness of ashwagandha in relieving knee pain among 60 participants. The study lasted 12 weeks and observed significant pain reduction in the ashwagandha group.
- Turmeric: Like ashwagandha and fish oil, turmeric is a natural supplement with a demonstrated ability to reduce inflammation. Choose a supplement combining turmeric with an extract of black pepper, which helps the body absorb the curcumin from the turmeric. While no studies of turmeric and fibromyalgia exist, a 2016 review published in the Journal of Medicinal Food examined the effectiveness of turmeric as an arthritis treatment. The review found evidence to support turmeric’s effectiveness but also concluded that the subject requires further study to make any definitive conclusions.