By Yoel Sitbon, PhD
Medical cannabis has now become legal in an increasing number of states, which means more consumers than ever are able to try these products. As such, they need to properly understand how to individualize its use and dosage for themselves. Self-medication is the most common method of medical cannabis use, but since it typically does not occur in a controlled setting such as a laboratory or hospital, there are very limited data to understand this practice. To avoid problems with overuse or misuse, consumers should be guided by an educated physician who specializes in medical cannabis and will discuss the most appropriate and personalized approach. This include the various chemovars associated with different relative amounts of THC vs. CBD as well as the most appropriate route of administration (e.g., smoking, vaporization, edibles…). For self-titration, medical experts advise the “start low and go slow” approach when identifying the right dosage for each molecule to provide the most benefits with the fewest side effects.
Today’s guest speaker on the Doctor’s Lounge is Dr. Dustin Sulak, D.O, an osteopathic physician, and expert in integrative medicine, which is the intelligent combination of conventional and alternative approaches to healthcare. Dr. Sulak’s clinical practice focuses on treating refractory conditions in adults and children and is the founder of Integr8 Health and Healer.com, a medical cannabis education resource.
There has been a dramatic shift in the regulation of medical cannabis in the United States, beginning when California legalized its use with the recommendation of a physician in 1996. Since then, medical cannabis has become legal in an increasing number of states, which means more consumers than ever are able to try these products for themselves. Because cannabis remains categorized as a Schedule I drug by the federal government, consumers are likely miseducated or undereducated about its medical potential.1 Consumers need to properly understand the plant’s chemical constituents and also how to individualize its proper use and dosage for themselves.
Cannabis plants produce more than 500 active compounds including phytocannabinoids (e.g., delta-9-tetrahydrocannabinol (Δ9-THC), delta-8-tetrahydrocannabinol (Δ8-THC), cannabidiol (CBD)) which are responsible for its recreational and medical uses, as well as other organic compounds, such as flavonoids and terpenoids, which produce cannabis’ color, taste, and aroma. The relative proportions and amounts of these molecules may also vary depending on the specific types of cannabis plant being grown, and thus consumers should be aware of the differences in various chemically-distinct cultivars, or “chemovars.”2 THC and CBD, the most-investigated compounds, act differently on the endocannabinoid system, specifically on the receptors CB1 and CB2 which are widely distributed throughout the human body.3 CB1 receptors are most abundant in the gastrointestinal tract, while CB2 receptors are primarily expressed on immune cells and tissues, and both are found in the central nervous system (CNS).4,5 THC and CBD also act in opposite ways; THC activates pathways associated with feelings of euphoria, whereas CBD does not.6,7
Self-medication is the most common method of medical cannabis use, but since it typically does not occur in a controlled setting such as a laboratory or hospital, there are limited data on this practice. Self-medication refers to one of two behaviors: 1) the conscious use of nonprescribed medication to treat a condition or 2) the use of an illicit drug to consciously or subconsciously treat a physical or psychological condition.8 To avoid problems with cannabis overuse or misuse, consumers should be guided by an educated physician who specializes in medical cannabis and will discuss the most appropriate and personalized approach. Depending on the individual’s previous tolerance to cannabis, chosen route of administration, or susceptibility to anxiety-like symptoms, one needs to carefully understand and experiment with the various chemovars available associated with different relative amounts of THC vs CBD.
Titration refers to the slow and steady addition of a substance in order to accurately determine the amount which confers an effective result. For self-titration, medical experts advise the “start low and go slow” approach when identifying the right dosage for each molecule, as this will provide the most beneficial effects with the fewest side effects.9,10 In other words, an individual seeking to self-titrate in order to maximize their chances of finding the most effective and sustainable relief should start with the smallest possible dose over the course of several days and slowly increase if needed. Furthermore, experts recommend using a journal to keep track of previous cannabis use, record the time and amount of the current product dosage, whether it was taken on an empty stomach, if other medicines were taken along with it, how long it took to feel the effects, and the overall changes compared with previous dose level.11 The use of the Releaf AppTM, developed in 2016, is another way to identify the most effective products, track the best dosing and administration methods, and improve a self-directed medical cannabis experience.12
There are several methods of administration one can use to self-administer medical cannabis products, each with potential benefits and drawbacks. While inhalation of smoked cannabis is a fast and convenient method of self-titrating, toxic compounds such as tar or carbon monoxide may exacerbate existing health issues (especially when combined with tobacco).13,14 An alternative is vaporization or volatilization, which reduces the production of harmful biproducts while still offering rapid delivery into the bloodstream to maximize its therapeutic potential.15 The use of cannabis-infused edibles (e.g., cookies, candies, beverages) have increased in recent years due to the perception that they are safer than smoking have a longer duration of action.16 However, edible products may be a challenge for self-titration, as the amounts of active molecules are often inexact, and they may be associated with unintentional overdosing, resulting in hallucinations, delusions and anxiety in some individuals.17,18 Other methods of administration such as topicals, suppositories, or concentrates are available to consumers, but these require further study before they are reliable for self-titration.
Several studies have evaluated self-administration of cannabis in the context of pathological disease as well as for improving quality of life, specifically focusing on the management of pain, anxiety, and depression.19 A study of patients with advanced cancer showed that self-titration to an optimal dose of THC:CBD was more beneficial in relieving pain than a placebo control.20 Another study of patients with cancer using a THC/CBD oromucosal spray also showed an benefit from self-medication, with improvement of insomnia, pain, and fatigue without needing to increase their non-cannabis pain medication.21 Using the Releaf App as a self-titration tool, patients experienced a greater benefit to pain management, agitation/irritability, and anxiety from cannabis flower with higher THC levels compared to other types of cannabis products.22,23 A similar study of people suffering from insomnia showed that self-titration with vaporization was more effective than smoking, while chemovars with higher CBD were equally effective as those with higher THC.24 This suggests that consumers should expect different effects from self-titrating medical cannabis products depending on the type of symptoms they are looking to manage.
With more states approving recreational and medical cannabis, there is a critical need to further investigate the benefits and drawbacks of cannabis self-administration among consumers. While low dosages have shown to be beneficial, several reports have indicated that high dosage and/or increased frequency was associated with greater number of psychological outcomes and potential self-dependence.25-30 Additional research in this area is necessary, and all consumers should consult with a physician specializing in medical cannabis when embarking on any self-titration approach.
- Gabay M. The federal controlled substances act: schedules and pharmacy registration. Hosp Pharm 2013;48(6):473-4. DOI: 10.1310/hpj4806-473.
- ElSohly MA, Radwan MM, Gul W, Chandra S, Galal A. Phytochemistry of Cannabis sativa L. Prog Chem Org Nat Prod 2017;103:1-36. DOI: 10.1007/978-3-319-45541-9_1.
- Devane WA, Hanus L, Breuer A, et al. Isolation and structure of a brain constituent that binds to the cannabinoid receptor. Science 1992;258(5090):1946-9. DOI: 10.1126/science.1470919.
- Hill KP, Palastro MD, Johnson B, Ditre JW. Cannabis and Pain: A Clinical Review. Cannabis Cannabinoid Res 2017;2(1):96-104. DOI: 10.1089/can.2017.0017.
- Atwood BK, Mackie K. CB2: a cannabinoid receptor with an identity crisis. Br J Pharmacol 2010;160(3):467-79. DOI: 10.1111/j.1476-5381.2010.00729.x.
- Pisanti S, Malfitano AM, Ciaglia E, et al. Cannabidiol: State of the art and new challenges for therapeutic applications. Pharmacol Ther 2017;175:133-150. DOI: 10.1016/j.pharmthera.2017.02.041.
- Di Marzo V, Melck D, Bisogno T, De Petrocellis L. Endocannabinoids: endogenous cannabinoid receptor ligands with neuromodulatory action. Trends Neurosci 1998;21(12):521-8. DOI: 10.1016/s0166-2236(98)01283-1.
- Suh JJ, Ruffins, S., Robins, C.E., Albanese, M.J, Khantizian, E.J. Self-medication hypothesis – connecting affective experience and drug choice. APA 2008;25 (3)(518-532). DOI: 10.1037/0736-97184.108.40.2068.
- Lucas CJ, Galettis P, Schneider J. The pharmacokinetics and the pharmacodynamics of cannabinoids. Br J Clin Pharmacol 2018;84(11):2477-2482. DOI: 10.1111/bcp.13710.
- Sulak D. Cannabis Dosing: Less is (Usually) More. (https://healer.com/cannabis-dosing-less-is-usually-more/).
- Cannabis as Medicine: How to Dial in Your Dose by Self-Titrating. (https://www.thehigherpath.com/cannabis-dosage/).
- Releaf App. (https://releafapp.com/).
- Hazekamp A, Ware MA, Muller-Vahl KR, Abrams D, Grotenhermen F. The medicinal use of cannabis and cannabinoids–an international cross-sectional survey on administration forms. J Psychoactive Drugs 2013;45(3):199-210. DOI: 10.1080/02791072.2013.805976.
- Mehra R, Moore BA, Crothers K, Tetrault J, Fiellin DA. The association between marijuana smoking and lung cancer: a systematic review. Arch Intern Med 2006;166(13):1359-67. DOI: 10.1001/archinte.166.13.1359.
- Abrams DI, Vizoso HP, Shade SB, Jay C, Kelly ME, Benowitz NL. Vaporization as a smokeless cannabis delivery system: a pilot study. Clin Pharmacol Ther 2007;82(5):572-8. DOI: 10.1038/sj.clpt.6100200.
- Huestis MA. Human cannabinoid pharmacokinetics. Chem Biodivers 2007;4(8):1770-804. DOI: 10.1002/cbdv.200790152.
- Wilkinson ST, Radhakrishnan R, D’Souza DC. Impact of Cannabis Use on the Development of Psychotic Disorders. Curr Addict Rep 2014;1(2):115-128. DOI: 10.1007/s40429-014-0018-7.
- Barrus DG, Capogrossi KL, Cates SC, et al. Tasty THC: Promises and Challenges of Cannabis Edibles. Methods Rep RTI Press 2016;2016. DOI: 10.3768/rtipress.2016.op.0035.1611.
- Kosiba JD, Maisto SA, Ditre JW. Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: Systematic review and meta-analysis. Soc Sci Med 2019;233:181-192. DOI: 10.1016/j.socscimed.2019.06.005.
- Johnson JR, Burnell-Nugent M, Lossignol D, Ganae-Motan ED, Potts R, Fallon MT. Multicenter, double-blind, randomized, placebo-controlled, parallel-group study of the efficacy, safety, and tolerability of THC:CBD extract and THC extract in patients with intractable cancer-related pain. J Pain Symptom Manage 2010;39(2):167-79. DOI: 10.1016/j.jpainsymman.2009.06.008.
- Johnson JR, Lossignol D, Burnell-Nugent M, Fallon MT. An open-label extension study to investigate the long-term safety and tolerability of THC/CBD oromucosal spray and oromucosal THC spray in patients with terminal cancer-related pain refractory to strong opioid analgesics. J Pain Symptom Manage 2013;46(2):207-18. DOI: 10.1016/j.jpainsymman.2012.07.014.
- Stith SS, Li X, Diviant JP, et al. The effectiveness of inhaled Cannabis flower for the treatment of agitation/irritability, anxiety, and common stress. J Cannabis Res 2020;2(1):47. DOI: 10.1186/s42238-020-00051-z.
- Li X, Vigil JM, Stith SS, Brockelman F, Keeling K, Hall B. The effectiveness of self-directed medical cannabis treatment for pain. Complement Ther Med 2019;46:123-130. DOI: 10.1016/j.ctim.2019.07.022.
- Vigil JM, Stith SS, Diviant JP, Brockelman F, Keeling K, Hall B. Effectiveness of Raw, Natural Medical Cannabis Flower for Treating Insomnia under Naturalistic Conditions. Medicines (Basel) 2018;5(3). DOI: 10.3390/medicines5030075.
- Stinson FS, Ruan WJ, Pickering R, Grant BF. Cannabis use disorders in the USA: prevalence, correlates and co-morbidity. Psychol Med 2006;36(10):1447-60. DOI: 10.1017/S0033291706008361.
- Chen CY, Wagner FA, Anthony JC. Marijuana use and the risk of Major Depressive Episode. Epidemiological evidence from the United States National Comorbidity Survey. Soc Psychiatry Psychiatr Epidemiol 2002;37(5):199-206. DOI: 10.1007/s00127-002-0541-z.
- Crippa JA, Zuardi AW, Martin-Santos R, et al. Cannabis and anxiety: a critical review of the evidence. Hum Psychopharmacol 2009;24(7):515-23. DOI: 10.1002/hup.1048.
- Waldman M, Hochhauser E, Fishbein M, Aravot D, Shainberg A, Sarne Y. An ultra-low dose of tetrahydrocannabinol provides cardioprotection. Biochem Pharmacol 2013;85(11):1626-33. DOI: 10.1016/j.bcp.2013.03.014.
- Nguyen BM, Kim D, Bricker S, et al. Effect of marijuana use on outcomes in traumatic brain injury. Am Surg 2014;80(10):979-83. DOI: 10.1177/000313481408001015.
- Portenoy RK, Ganae-Motan ED, Allende S, et al. Nabiximols for opioid-treated cancer patients with poorly-controlled chronic pain: a randomized, placebo-controlled, graded-dose trial. J Pain 2012;13(5):438-49. DOI: 10.1016/j.jpain.2012.01.003.