Welcome to an awesome world where people of all races, ages, and socioeconomic levels are learning about the benefit of medical cannabis!
As you start your journey using cannabis as part of your life here are the basics everyone should be aware of!
Dr. D TV: What should you discuss with your cannabis physician? What questions should you ask?
As promised here are my most common recommendations based on my experience with thousands of patients. Please read the whole 101 section for more information.
Cannabis today is PERSONALIZED medicine, based on you, your goals, your past experiences, your tolerance, and what you are attempting to treat. Todays cannabis medicines allow you to tailor the experience and psychoactivity to what works best for you. HOWEVER…. research and the majority of anecdotal reports show that especially for chronic pain and inflammation CBD and THC together work much better to help many conditions than CBD all alone. The 1:1 ratio of CBD accomplishes pain relief very nicely. Strains like Blue Jay naturally produce CBD and THC in 3:2 or so ratios. An interesting fact – Cannabis is like wine in the fact that harvest dates can affect the composition of the plant and how much of each cannabinoid has been produced.
Another interesting fact… is that much past research has been on single molecule preparations… because thats how researchers do research. However, the new cannabinoid medications you see appear in a CVS near you in the future will be multiple cannabinoids in one product in many cases.
We must revisit the topic of personalized medicine again here… if you are the person that does very well with THC and enjoys the high then a 1:1 ratio may be a great place to start, where if you are brand new or have not liked THC in the past you should start at a lower concentration of THC – like a 3:1 ratio of CBD:THC.
There are more to things than just the ratio… you also have to consider how many milligrams you are taking of both the CBD and THC if using a tincture or edible so you can remember what works for you. With vapor the effects are so immediate you simply titrate to effect… meaning inhale and wait and see how you feel 15 minutes later and inhale again, very soon you will have found your functional dose, by which I mean you will know something like “Ok, after 3 inhalations I feel great, 1 is not enough, 6 is too much for me to be functional”
Unfortunately we must still break down the stigma around the cannabis “high” that the federal government has so wrongly stigmatized. Let me tell you… from working as a physician for years the hospitals are full of patients enjoying their opiate “high” and pain relief and we don’t see Jeff “the NeoProhibitionist” Sessions yelling at people for enjoying their opiate high. Truly disheartening to see so many supposedly smart people completely uninformed on the real world dynamics of helping people and what the real risks are, because in the face of the opiod epidemic I can assure you the cannabis high is NOT the enemy… in fact we have a term for when a patient in the hospital are given too many narcotics and become drowsy or over drugged, we call them “snowed”, snowed out on opiates and people get snowed all the time. Maybe a patient requests more meds then they can handle, maybe the nurse doesn’t evaluate the patient correctly, maybe the patient is abusing opiates illegally brought into the hospital, maybe the patient is in so much pain they would rather fall to sleep from opiates then deal with it.
Everything in medicine has a risk and a benefit… the cannabis high… is it a benefit or a risk? Well I would strongly urge you to view it as a pleasant side effect in a world where most medications have much worse side effects, like death, constipation, liver damage and more.
So based on your history with cannabis, whether you enjoy the THC high or not, what time of day it is, and what you are treating can all play a roll in where to start in the cannabis pharmacy.
For chronic pain – based on YOUR personal preference try either a vaporizer, tincture, or lozenge for rapid control of break thru pain, anxiety, and to aid in sleep. Use as needed. Follow directions on packaging. Try a 1:1 ratio of CBD:THC as a starting point and see how that works for you. If you desire less psychoactivity try a 2:1,3:1, or 4:1 ratio or higher of CBD:THC. If you desire more psychoactivity try a full THC tincture, or indica, hybrid or sativa vape cartridge.
As I said above… what time of the day it is also factors into how many people use cannabis with many people taking advantage of the sleep inducing effects of THC by using a more THC dominant product in the evening, and a lighter product during the day with more CBD, like a 1:1, 2:1 or 3:1 ratio.
An interesting finding to note is that remember CBD does have the ability to strongly inhibit certain enzymes that process drugs… If you use a whole plant product with both THC and CBD… you will not have to take the mega doses of CBD that you otherwise may have needed to find relief.. thus diminishing cannabinoid inhibition of enzymes and medication interactions.
If a person is very new to cannabis or has had bad experiences with THC in the past, then they should be started on more CBD heavy formulas first like 8:1 ratio and slowly over days or weeks brought up to trying a 1:1 ratio if they can tolerate it to see if they get more pain relieving effects from using near equal ratios as shown in the literature. Do NOT let the stigma of the cannabis high cause you to not try scientifically formulated whole plant medicine.
I prefer to start most patients with vapor or sublinguals because the time of onset is rapid 5-15 minutes and patients can easily take a small dosage then evaluate how they feel in 20 minutes. If a patient needs more relief they can slowly take more by taking small puffs or sprays under the tongue – and get themselves to a point of symptom relief, while remaining functional and not overdosing.
For conditions such as anxiety, depression, schizophrenia and other mental health conditions CBD dominant medications have been shown to be what most people respond best too.
– In regards to topicals there is some research showing they help neuropathic pain. See: https://www.ncbi.nlm.nih.gov/pubmed/19744255 Pretty much any other claim is not yet validated by science, so folks that tell you it helps joint pain etc are relying purely on patient anecdotes and marketing. Evaluate products based on the value (cost vs milligrams of CBD and THC in the product)
– What about edibles? I like to recommend small edibles clearly divided into 5 or 10mg servings or infused coffees/teas of the same strength. For those who have not used much cannabis a starting dosage would be 5 or 10 mg of THC. I would use a product that contains an equal amount of CBD, if possible. Remember edibles can take up to 1-2 hours to feel effects.
– If the above recommendations do not help or if you have severe arthritis, inflammatory or autoimmune conditions, seizures or pain you can also try adding in CBD rich oil by capsule or oil by mouth. I recommend starting at an 18:1 ratio of CBD:THC, 25mg in the AM and 25mg in the PM for one week and then evaluate if helping. If relief is not achieved at that point we work with patients to either increase dose or lower the ratio to see if more THC in the mixture helps. For reference in certain clinical trials patients were dosed at 200mg-600mg of CBD per day, however most people could never afford that dose – point being there is a lot of room to dose CBD at without serious side effects. We also discuss adding THCa. ** An important caveat to add here is that when using oils or capsules you should also check with the manufacturer of the oil as to what their recommended dosage is as there can be variation in the concentrations of active ingredients, for example a few milliliters of one cannabis oil may not have the same amount of the active ingredient in it as another.
We start patients low and go slow with increases. For patients inquiring about using CBD as a anti-seizure medication should look at the latest peer reviewed papers regarding epilepsy and cannabis, common doses are wide ranging. We have many posted in the research paper section here. We advise looking for the latest clinical trials for what the latest effective dosages seem to be and will update as they are released.
For patients wishing to use cannabis as an adjuvant to their cancer treatment we discuss with patients how much oil they should eat depending on their history of cannabis use and what goals should be.
I hope that helps!!
Donald Davidson, M.D.
P.S. If you still have questions you can ask them free in our forum here!
Warning: Cannabis remains a schedule 1 substance according to the US federal government.
What is cannabis?
A wonderful plant which produces cannabinoids that can interact with the human endocannabinoid system in ways which can improve our lives when used properly!
The flowering tops of the female cannabis plant have been smoked or had the cannabinoids extracted from them for medical purposes for centuries.
The most common problems I see patients for that are getting relief from cannabis use are trouble sleeping, anxiety, migraines, pain around menstrual cycles, arthritis, joint pain, itching from psoriasis or eczema, cancer, neuropathy, depression, epilepsy, back pain from fusions or herniated discs, chrons disease, ulcerative colitis, multiple sclerosis, bipolar disorder, IBS, scoliosis, pain from old fractures, glaucoma, anorexia, medication/chemo side effects, ADHD, fibromyalgia, gout pain, parkinsons, PTSD, RLS, and more.
Many, many people are turning to cannabinoids instead of narcotics, NSAIDs, sleeping pills, or alcohol!
To access the plant and its derivatives in many states you will need a recommendation. IF you are in California you can get that by clicking HERE! Once you have a “rec” you will be admitted to dispensaries where you can buy cannabis as well as be able to order cannabis for delivery from companies which specialize in that.
What is a recommendation?
A medical marijuana recommendation is a document that states that the specified person has a medical condition that adheres to qualifying conditions stated under the state of California under California Proposition 215.
A recommendation is not a prescription but is a document that is necessary to legally purchase cannabis in a state that allows for legal medical cannabis use.
To see our FAQ section about getting your cannabis recommendation with us click HERE!
What do I do with my recommendation?
Once you get your recommendation you will need to pick how you will access cannabis products.
First you will need to decide whether you will go to a dispensary or delivery service. Eaze.MD syncs instantly to let you order delivery via the technology service Eaze. Another resource is Weedmaps.com, a website and APP which will show you dispensaries and delivery services in your area, think of weedmaps.com as the Yelp of cannabis stores.
I always recommend finding a very reputable dispensary or delivery company with a wide product array (read multiple brands of everything) to go to in order to be shown an array of products and pick what is right for you. You will likely want a dispensary that carries more than just flowers. Feel free to call ahead or browse the dispensary or delivery company’s website, reputable places will have educated staff (called bud tenders) that can assist you with product selection, if not find a better service. All products should be lab tested, if not, find a better store!
What should I as an informed patient know about cannabis? What makes the plant work?
That, my friends, is a great question and one that science is rapidly unraveling. Check out our Research Papers and Clinical Trials sections on the website to read details on how cannabis works to treat certain diseases and improve wellness.
As far as what works best for what conditions, that can be hard to say definitively without more clinical trials, but we go forward on the experiences of thousands and thousands of patients and a rapidly expanding base of research.
Indica flower or extracts are often used to treat anxiety, PTSD, migraines, trouble falling to sleep and pain, while Sativas are known to be more uplifting and better for focus, daytime use, and lifting one out of depression, however, you should try both indica, sativa and hybrids to see what you find the most relief from!
Patients are reporting relief from topicals for muscle soreness, arthritic joint pain, diabetic neuropathy, tension in neck and temples associated with migraines and on the lower abdomen for menstrual cramps. There is some interesting research on cannabis topicals.
Highly concentrated oils taken by mouth with different rations of CBD:THC are used for epilepsy, cancer, severe arthritis, autism, autoimmune disorders, neurodegenerative conditions, and more.
The crash course on cannabis to get you a knowledge of the common products and basic science is below:
The body contains the Endocannabinoid system which consists of at least the CB1 and CB2 receptors to which both endogenous and exogenous cannabinoids bind with.
The most common cannabinoids you will find on the market in high concentrations are THC, CBD, and to a lesser extent THCa. There are many more minor cannabinoids within cannabis.
THC is the cannabinoid that gives you the euphoric feeling, but also has important functions that are pain relieving, give a sense of well-being, anti-tumor and much more.
CBD is non psychoactive, but plays important roles in preventing seizures, pain control, is anti-inflammatory, has roles in relieving anxiety and aiding in PTSD treatment to name a few. CBD also appears in research to tone down the psychoactivity of THC and is being developed into a rescue agent to aid those that have overdosed on THC and are experiencing anxiety.
THCa is the non psychoactive precursor to THC. THCa turns to THC when heated. THCa is showing to have antiinflammatory properties as well as antiseizure properties.
A species of the Cannabis family known for pain relieving and anxiolytic qualities. Commonly used to treat insomnia.
A species of the Cannabis family known for its uplifting and energetic properties. Suited for day use.
Dr. D, how do I find my optimal dosage using a vaporizer or tincture? I heard there can be a “sensitization period” or where some people do not feel any effects from cannabis the first few times they use it?
We want you to have a great experience with cannabis!
First recognize that current research seems to support a “less is more” approach to using cannabis to stimulate the endocannabinoid system. The lowest effective dose for you should be used in order to reduce tolerance development and unwanted side effects.
Some patients do not report feeling anything the first few times they use cannabis. The reason for the ‘sensitization’ period where some people do not feel any effect from cannabis appears to be from the fact that THC can increase cannabinoid receptor production, while large doses can lower the cannabinoid receptor concentration. The ‘sensitization’ period is why we have people follow a minimal dosage for the first few days as receptors build.
There is no set dosage of cannabis as different people react differently and this is why following our program will help you find your own individual therapeutic dosage.
Day 1: Goal is to find the minimum amount of cannabis you need to feel the effect. You may not feel any effects, do not be worried if that is the case.
Vaporization: Take 1 inhalation from your vapor pen or vaporizer and then wait 5-15 minutes and see how you feel. If you feel at all altered stop and take no more inhalations. If you do not feel different at all take another inhalation and wait another 5-15 minutes. Reassess. Take up to 3 inhalations total, but no more at this point.
Tincture: Take half the manufacturer’s recommended dosage and wait 20 minutes. If you feel anything, stop, if not repeat once more.
Day 2: Goal is to continue to increase sensitivity to cannabis. Follow same instructions as day 1
Day 3: Proceed in the same manner as day 1 and 2, but stop not once you feel the slightest effect of cannabis, but instead stop once you get relief from your symptoms. The minimum dosage that gives you symptom relief is your therapeutic dose! If you take 3 inhalations and find no effect, extend this process to a fourth day.
Now that you have sensitized yourself to cannabis and know your therapeutic dose you can use cannabis as needed to treat your symptoms.
I heard about the CBD:THC ratio, what is that?
The research seems to support that THC and CBD do a better job of treating many conditions together than alone. However, certain diseases may respond better to higher concentrations of CBD as well as certain patients are more sensitive to THC than others and prefer to get the benefits of cannabinoids without so much psychoactivity. To that accord products have been developed with ratios of CBD:THC that range from 24:1, 18:1, 12:1, 8:1, 4:1, 2:1, 1:1 all the way to the other end of the spectrum of products containing almost pure THC. You will likely not experience much psychoactivity until you begin using products in the 4:1 ratio or lower (depending on dosage of course).
Most cannabis flower is high in THC and low in CBD, you should always ask for what you want and good dispensaries will have the tested cannabinoid profiles of all their flower displayed prominently.
What is the Entourage Effect?
You may also hear about The Entourage Effect, this is what is referred to as the feeling or effects on your body produced by consuming whole plant cannabis or its derivatives, in opposition to simply using an isolated THC preparation or a lab synthesized cannabinoid product containing only one cannabinoid. The entourage effect is the cumulative effect of all the cannabinoids and terpenes on you.
Different people can react to cannabis differently.
Always start slowly, take a small inhalation if vaporizing and hold briefly and then evaluate how you feel 10-20 minutes later to see if you need any more medicine or are comfortable.
Read sublingual and edible labels carefully and always start with a half the full dose. New patients should never eat more than a 10mg edible. See below for more information on ways to consume cannabis products and their time of onset.
Dr. D what are the healthier ways to consume medical cannabis products?”
The different ways to administer medical cannabis
Vaporizing cannabis is heating the cannabis to a temperature hot enough for the cannabinoids to vaporize and be inhaled but below the burning point of the leaf matter, thus greatly decreasing the amount of carcinogens you inhale.
There are two major type of vaping one using a small device that vaporizes ground up cannabis buds or a pen type that accepts a cannabis oil concentrate. There are also larger desk top at home models that blow heated air across ground bud to inflate balloons. Both work well, but the vape pens win for convenience these days.
Time of onset of effects of cannabis by vaping are 5-10 minutes and last about 2-4 hours. New users should take 1-2 inhalations and wait 15-20 minutes before evaluating if they are comfortable or they need to medicate more inhalations for relief.
Vaporizing is proven to deliver the active cannabinoids patients desire without the harmful byproducts of smoke. See this article.
Vaporizing dry cannabis vs concentrates / Oil cartridges on vape pens
Vaporizing whole marijuana
Dry cannabis is ground in a grinder and then sprinkled into a small oven or chamber that will heat and vaporize the cannabinoids while you inhale through the mouthpiece.
Since terpenoids have the lowest boiling point, around 132°F, they are typically the first compounds to be released by vaporizing. Studies have found that the sweet spot for vaporizing cannabis is around 338°F, even though cannabinoids [the medicinal compounds found in the cannabis plant] begin to vaporize at 285°F.
These concentrates give you the benefit of only needing a very small amount of the product to get the same effect as smoking. The oil is heated until vaporization occurs while you inhale through the mouth piece. The heating element is either activated by depressing a button or even by the simple act of inhaling on the device.
Hand held cannabis flower vape
Table top large vaporizer
How to use a cannabis vape pen
Medical Cannabis Edibles
Food containing the cannabinoids. For example: gummy bears, cookies, or brownies. 10 mg of THC is a common starting recommendation, but follow manufacturers recommendations. Time of onset is 1-2 hours and effects can last about 4-8 hours. Cons can be that these products are hard to dose and often contain lots of sugar. Be careful not to overdose, you can’t take out what you put in.
Medical Cannabis Beverages
Cannabis-infused teas, coffee, juices, smoothies, and sodas. You can make your own cannabis tea by steeping cannabis in hot water. Time of onset varies between 30 minutes to 2 hours. Duration of effects last about 3-5 hours.
Sublinguals: Medical Marijuana Tinctures, Sprays, or lozenges
Tinctures and sprays are extracted cannabinoids mixed into an alcohol or coconut solution. With a tincture you drop the manufacturers recommendation of drops under your tongue to start with and then wait 10-20 minutes to feel the effects at which point you can either take more if needed or else decide you have enough relief and redose in 3-4 hours. The same rules apply for sprays and lozenges you let dissolve in your mouth or under your tongue.
How to use medical cannabis sublingually
Cannabis Oil Extract
The highly concentrated oils are made up of different ratios of cannabinoids, usually CBD to THC, that can be used for treating a wide array of conditions.
Common ratios you will find are:
Transdermal patches and topicals
Patches and topicals are great for arthritis, itchy skin from psoriasis or eczema, minor burns, muscle soreness, sunburns, and joint pain. Patches are recommended for areas of the body with little hair.
How to use topical medicinal cannabis products
Suppositories (Both Vaginal and Anal)
Great for patients with problems taking oral medications. Treatments also available in vaginal suppository form for women to help treat PMS pain.
How it works: Certain medicinal properties are lost when the plant is dried or heated as THCa is converted to THC. To consume cannabis raw you eat the raw leaves and buds straight from the plant or more commonly by adding them to a juice mix or smoothie with other vegtables. Starting recommendations are 15 leaves a day and one or two 3 inch buds.
Potential Side Effects of Cannabis and Risks
The most common way people overdose is by eating edibles, remember these products can take 1-2 hours to take effect.
Medical Cannabis has a potent analgesic effect and can mask symptoms of serious illness. Make sure you know your diagnosis before starting on a treatment plan with medical Cannabis.
Common side effects: changes in balance and fine-motor control, tiredness, anxiety, dry mouth, increased appetite, and short term memory loss
Smoke can exacerbate preexisting airway disease like COPD
Addiction. That 5-9% of users become addicted.
Withdrawal symptoms – Daily users can experience irritability and other symptoms of withdrawal if they abruptly stop using cannabis products.
Cannabis intoxication causes short term impairment in memory, problem solving, reaction time and should not be used while driving or operating heavy machinery.
Cannabis can cause transient mood, anxiety and psychotic symptoms.
Chronic Obstructive Pulmonary Disease has been shown to be a greater risk to those that smoke both cigarettes and cannabis.
Cannabis compounds cross the placenta and enter into breast milk and are associated with low birth weight and developmental delay and behavioral problems and should never be used by breast feeding or pregnant women.
Cannabis can lower blood pressure and strain the heart at times by producing tachycardia and patients should consult their cardiologist if they have ischemic heart disease or low blood pressure.
If you are immunosuppressed due to HIV, organ transplant, alcoholism, or intravenous feeding you should not smoke or vaporize cannabis because it can have fungus in the marijuana which could cause sinus and lung infections. Instead choose the sublingual or edible route.