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Optimal Cannabis
Dosing
A physician’s perspective
on optimal cannabis dosing
Dr. Dustin Sulak
Dosage
is the key factor in achieving the most benefits and least adverse effects of
cannabis.
After
following thousands of patients using medical cannabis for eight years, I’ve
observed that dosing cannabis is unlike any therapeutic agent to which I was
exposed in my medical training.
A
basic understanding of the key characteristics of cannabis dosing can empower you
to make the most of this incredibly versatile, safe, and effective herb.
Some
patients effectively use tiny amounts of cannabis, while others use incredibly
high doses.
I’ve
seen adult patients achieve therapeutic effects at 1 mg of total cannabinoids daily,
while others consume over 2,000 mg daily without adverse effects.
And
while a 2000-fold dosing range is unusual for a medication, researchers have
failed to kill monkeys at doses even 300 times higher than the highest dose
I’ve observed in the clinic.
Multiphasic
dose-response relationships
Within
this unusually broad dosing range, cannabis exhibits an unusual relationship
between the dose and the expected response.
For
most medications, a higher dose will result in a stronger therapeutic effect
and a higher likelihood of adverse effects; this is described as a monophasic
dose-response relationship. Cannabis simply does not follow this pattern.
For
most cannabis consumers, gradually increasing their dose will at first result
in stronger effects; but after a certain point (unique to each individual),
subsequent dosage increases can result in weaker and weaker therapeutic
effects, accompanied by an increase in unwanted effects.
Consumers
who continue to increase their dosage to very high levels can often reclaim
some or all of the previously lost benefit, and sometimes find additional
therapeutic effects not achieved at the lower doses.
Of
course, ultra-high doses are much more expensive and usually produce more
unwanted side effects. Most patients do much better at the lowest effective
dose.
For
many cannabis users, this means that less can be more.
In
a study of 263 opioid-treated cancer patients with poorly controlled pain, the
group receiving 21 mg of combined THC and CBD each day experienced significant improvements
in pain levels, more so than the group that received 52 mg daily.
The
group that received 83 mg daily reduced their pain no better than placebo, but
experienced more adverse effects.
Cannabis
has the ability to produce opposite effects in different people, with different
strains, and at different dosages.
How
is this possible? The endocannabinoid system is a sensitive, highly tuned
physiologic infrastructure designed to maintain balance at a cellular level.
When
the cannabinoid receptors become overstimulated by high doses of cannabis, the
cells pull the receptors inside, where they are either recycled or degraded.
As
cannabinoid receptor levels diminish, the effects of cannabis will diminish as
well, even (or especially) in the face of dose escalation.
This
is known as “tolerance-building,” something that many regular cannabis users
have experienced.
Therapeutic
window
The
term “therapeutic window” describes the range between the lowest effective dose
and the dose that produces unwanted or intolerable side effects.
People
who have little or no experience using cannabis typically have a very narrow
therapeutic window, while regular users develop a wider therapeutic window.
This
is due to the fact that individuals build tolerance to the various effects of
cannabis at different rates, and most build tolerance to the unwanted effects
faster than the desired effects.
Bidirectional
effects of cannabis
Cannabis
also has the ability to produce opposite (or bidirectional) effects in
different people, with different strains, and at different dosages.
For
example, anxious people who take cannabis may relax while non-anxious people
who take the same dose can become anxious.
The
same dose of two different varieties of cannabis can cause opposite effects –
one might be an awakening strain and the other might put you to sleep.
When
combined, CBD and THC can enhance each other’s benefits while reducing unwanted
effects.
Interestingly,
the symptoms of cannabis overdose closely mirror the symptoms one would expect
cannabis to relieve at appropriate doses: nausea, vomiting, diarrhea, sweating,
spasms, tremors, anxiety, panic attacks, paranoia, discoordination, and
disturbed sleep.
Extreme
overdoses can lead to hallucination and even acute psychosis.
Fortunately,
these symptoms are all self-limiting, and most people return to their normal
selves within 12 to 24 hours.
Even
though a cannabis overdose may make a person feel like they’re dying, such an
experience will cause no toxicity or permanent damage, except perhaps in people
who have unstable cardiovascular or psychiatric conditions, or in the case of
impairment leading to an accident.
Combining
CBD and THC
CBD
and THC have many overlapping therapeutic qualities, including relief of pain,
anxiety, seizures, and nausea, although they work via different mechanisms of
action.
When
combined, CBD and THC can enhance each other’s benefits while reducing unwanted
effects, including the psychoactive or impairing effects of THC.
This
is great news for cannabis users who want health benefits while maintain
optimal performance at home or work.
Ultra-low
doses of cannabis can be extremely effective, sometimes even more so than the
other extreme.
By
adding CBD to THC, the therapeutic window, described above, becomes even wider.
Consumers
should know, however, that the total dose of cannabinoids needed to treat a
symptom or condition will also likely increase.
For
example, in a study of 177 patients with cancer pain, one group received an
oral spray of THC, while another group received an oral spray of combined THC
and CBD at an approximate 1:1 ratio.
Both
groups were allowed to gradually increase their dose until they experienced
satisfactory relief.
The
THC group ended up using an average of 27 mg daily, while the CBD+THC group
used close to 60 total mg daily, but the CBD+THC group had a superior reduction
in pain.
I’ve
seen this in many patients–combine CBD and THC for optimal benefits, but be
prepared to take (and purchase) higher overall dosages.
Ultra-low
dosages
Some
patients do well with ultra-high doses (hundreds or thousands of milligrams
daily).
THC
consumers have to slowly work up to these high doses, but many patients can
quickly reach high doses of CBD without adverse effects.
On
the other hand, ultra-low doses can be extremely effective, sometimes even more
so than the other extreme.
Most
people are surprised to learn that the therapeutic effects of THC-dominant
cannabis can be achieved at dosages lower than those required to produce
euphoria or impairment.
Cannabis
microdosing, taking a non- or slightly psychoactive dose for the purpose of
improving heath and productivity, has been gaining popularity.
People
report better mood, reduced anxiety, improved focus, enhanced resilience to
stress, less pain (and/or less bothersome pain), and other benefits without any
adverse effects.
Most
consumers find that 1-5 mg works well for this purpose. Some emerging evidence
even suggests that a practice like this could be protective against the damage
of a heart attack.
Recommendations
for new and experienced consumers
For new cannabis users, I abide by an old adage I
learned from one of my geriatrics instructors: “Start low, go slow, and
don’t be afraid to go all the way.”
I’ve
developed an easy- to-follow program to help find your optimal dose, along with
other useful resources like a medical cannabis shopping guide, available free
on Healer.com.
For
existing users who may have built some tolerance to cannabis, I encourage you
to try my 6-day sensitization protocol, which has helped thousands of people
reduce their cannabis dose by 50% or more while improving the benefits.
If
you haven’t tried non-inhaled delivery methods such as tinctures or sprays, and
if you haven’t experimented with the combination of CBD and THC, I suspect that
both of these endeavors will help you continue to unlock the full power of this
incredible herb.
Dr. Dustin Sulak, DO, is the founder of Integr8 Health, a medical
practice in Maine that follows over 8,000 patients using medical cannabis;
Healer.com, a medical cannabis patient education resource; and Cannabis
Expertise, a continuing medical education curriculum. Recognized as a leading
clinician in the application of medical cannabis, Dr. Sulak is committed to
providing education to clinicians and patients on the use of medical cannabis.
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