Type 1 – Titrating THC
For adequate symptom relief, some patients may need to ingest a cannabis preparation two or three times during daylight hours in addition to their night-time regimen. Again, cautious titration is urged: On days 1 and 2, start with one dose of the equivalent of 2.5 mg THC; on days 3 and 4, increase to 2.5 mg THC twice a day; and, if well tolerated, up the dose incrementally to a total of 15 mg THC (divided equally throughout the day).
Doses exceeding 20-30 mg/day [of THC] may increase adverse events or induce tolerance without improving efficacy,” the authors warn.
Adverse events mainly pertain to THC and are dose-dependent. Very high doses are more likely to cause unwanted side effects.
For most medications, a higher dose will pack a stronger therapeutic punch. With cannabis, however, it’s not so simple. THC and other cannabis components have biphasic properties, meaning that low and high doses generate opposite effects. Small doses of cannabis tend to stimulate; large doses sedate.
In practical terms, this means that starting low and gradually upping the dose of cannabis will produce stronger effects at first. But, after a certain point, which differs for each person, “dosage increases can result in weaker therapeutic effects,” according to Dr. Sulak, “and an increase in side effects.”
Sulak observes that “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, dis-coordination, and disturbed sleep. Extreme overdoses can lead to hallucinations and even acute psychosis.”
Type 2 - THC and CBD: Power couple
Although many patients do well at the lowest effective dose, some benefit more from a high dose cannabis oil regimen, preferably one that includes a substantial amount of CBD as well as THC. By lowering the ceiling on THC’s psychoactivity, CBD makes high potency cannabis oil treatment easier to manage. If high doses are necessary, steady titration over several weeks will help build tolerance to THC’s tricky psychoactive effects.
CBD and THC are the power couple of cannabis therapeutics. Both compounds have remarkable medicinal attributes, and they work better in combination than as isolates. CBD can synergistically enhance THC’s anti-inflammatory and painkilling properties, for example, while reducing unwanted side effects.
A clinical study published in the Journal of Pain examined the efficacy of different dosage levels of Sativex, a cannabis-derived sublingual spray with 1:1 CBD:THC ratio, which is an approved medication in two dozen countries (but not in the United States). Of 263 cancer patients who were not finding pain relief with opiates, the group that received 21 mg of Sativex each day experienced significant improvements in pain levels, more so than the group that received 52 mg Sativex daily. And those given even higher doses (83 mg daily) reduced their pain no better than a placebo, but they experienced more adverse effects.
Cannabis therapeutics is personalized medicine. There is no single CBD:THC ratio or dosage that’s optimal for everyone. As little as 2.5 mg of CBD combined with a small amount of THC can have a therapeutic effect. If necessary, much higher doses of good quality CBD-rich formulations are safe and well tolerated.
For cannabis-naïve patients, it may be best to start with low doses of a CBD-rich remedy (with little THC) and increase the dosage (and, if necessary, the amount of THC) step-by-step. Take a few small doses over the course of the day, rather than one big dose.
But a low-THC product is not always the best treatment option. A more balanced combination of CBD and THC could have a greater impact than CBD or THC alone.
In essence, the goal is to administer consistent, measurable doses of a CBD-rich remedy with as much THCas a person is comfortable with. Experiment, observe the effects, and adjust the amount of CBD and THCuntil one finds the sweet spot with the right combination of both compounds.
Type 3 – Full-spectrum CBD-rich extracts
Microdosing cannabis is a feasible option for those who prefer not to leap over the psychoactive threshold. High dose CBD therapy is another way of healing without the high.
As a general rule, Type 3 CBD-dominant cannabis (with little THC) won’t make a person feel stoned. Nor will a pure CBD isolate (with no THC). But CBD isolates lack critical aromatic terpenes and other cannabinoids, which interact synergistically to enhance CBD’s therapeutic benefits. Single molecule cannabinoids are simply not as versatile or as efficacious as whole plant formulations.
Preclinical research indicates that full spectrum CBD-rich cannabis oil is effective at much lower doses and has a wider therapeutic window than a CBD isolate. “The therapeutic synergy observed with plant extracts results in the requirement for a lower amount of active components, with consequent reduced adverse side effects,” a
2015 Israeli study concluded.
In animal studies, CBD isolates require very high – and precise – doses to be effective. Problematic drug interactions are also more likely with a high-dose CBD isolate than with whole plant cannabis.
Hemp-derived CBD isolates and distillates are already available via numerous internet storefronts. Drug companies are also eyeing single molecule CBD as a treatment for intractable epilepsy, psychosis, and other diseases.
In a 2012 clinical trial involving 39 schizophrenics at a German hospital, 800 mg of pure pharmaceutical-grade CBD proved to be as effective as standard pharmaceutical treatments without causing the harsh side effects typically associated with antipsychotic drugs. But a follow-up study at Yale University found little cognitive improvement in schizophrenics who were given a CBD isolate.
Pharmaceutical CBD
Bereft of the THC stigma (and its therapeutic moxy), single-molecule CBD will soon become a FDA-approved pharmaceutical for pediatric seizure disorders. This is good news for families with epileptic children that have health insurance. Anyone without health insurance won’t be able to afford Epidiolex, a nearly pure CBD remedy developed by GWPharmaceuticals as an anti-seizure medication.
Consider the dosage range utilized in clinical trials of epidiolex. Children with catastrophic seizure disorders were given up to 50 mg of epidiolex per kg of body weight. Such high doses caused interactions with other anticonvulsant medications, requiring adjustments of the latter to avoid a toxic overdose.
By comparison, Dr. Bonni Goldstein, author of Cannabis Revealed, typically starts with a much lower dose of full spectrum CBD-rich oil (1 mg CBD/kg of body weight) for epileptic children – with the understanding that the dose may have to be lowered or raised depending on the initial response. If necessary, Goldstein will increase the dose of CBD by increments of 0.5 mg/kg until a threshold of 5 mg/kg of body weight is reached. And that amount also may need to be adjusted.[
Kids and adults metabolize drugs differently. It may seem counterintuitive, but young children can tolerate high doses of cannabis oil concentrates, including THC-rich formulations, which might be daunting for an adult. Thus, it’s not a good idea to calculate dosage for an adult based on what works for a child.
If 1 mg/kg of CBD is an appropriate starting dose for a child, and an adult weighs 15 times more than the child, one should not assume that the correct CBD starting dose for the grown-up is 15mg/kg of body weight. That could be way too high a dose. While CBD has no known adverse effects at any dose, an excessive amount of CBD may be less effective therapeutically than a moderate dose.
Similarly, it’s not a good idea to devise a dosage regimen based on data from preclinical animal studies, which usually involve high doses of single-molecule cannabinoids. Human metabolism differs from mice and rats, and data from animal models doesn’t always translate to human experience.[
Personalized medicine
For people as well as pets, cannabis dosing must be individually determined. Several factors come into play, including one’s overall health and endocannabinoid tone, which are influenced by diet, exercise, sleep patterns, day-to-day stress, and genetics. Cannabis is best used as part of a healthy lifestyle.[
Here are some dosing variables to consider:
- Cannabis experience. Is the patient cannabis-naïve? Or a stoner who already uses cannabis every day but isn’t getting the best results? A veteran user may need a higher dose than a new user. Or a chronic user might need a break from getting high to reboot his or her sensitivity to cannabis (see Dr. Dustin Sulak’s cannabis “sensitization protocol” on Healer.com).
- Time of day. Optimizing one’s therapeutic use of cannabis may entail using products with different CBD:THC ratios at different times of the day – more CBD for daylight hours, more THC at night.
- Preventive dosing. Prolonged low dose therapy may be advantageous for managing chronic symptoms or to prevent disease recurrence. Preclinical studies indicate that cannabinoids have neuroprotective and cardioprotective properties that could limit the damage of a traumatic brain injury or a heart attack.
- Cannabinoid acids. Raw, unheated cannabis contains CBD and THC in their “acid” form, CBDA and THCA, which are not intoxicating. Consumed orally over several months, cannabinoid acids can be effective in very small amounts, but precise dosing is difficult when juicing raw cannabis. Other delivery systems are becoming available for CBDA-rich and THCA-rich products.