Dosing Medical Cannabis: 10 Key Things to Consider
Article written by
Shanti RyleContent Writer
Content reviewed by
Dr. Lewis Jassey
People often don’t know where to start when dosing cannabis, particularly for several applicable conditions and each person’s unique physiology. People ask what ratio of THC: CBD to take, what strain they should choose, and what’s best for their condition(s).
In some ways, this questioning is good: because patients are becoming increasingly aware of the concept of chemovariance. Chemovariance refers to the various compounds and ratios in different cannabis strains (or, more accurately, varietals or cultivars) that could be more or less beneficial for a particular condition. The combination of the cannabis plant’s flavors (flavonoids), smells (terpenes), and cannabinoids all contribute to its unique effects – referred to as the entourage effect.
On the other hand, we still have much to learn when it comes to understanding ratios of cannabis’ many compounds for certain uses. Other variables, like age, sex, height, weight, lifestyle factors such as diet & exercise, intake of other medications, and the condition/s being suffered from also need to be taken into account. But research is growing, and while we lack studies, there are some key things a patient can consider when deciding what profiles and strains (varieties) may benefit them.
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1. Why are you using cannabis? Do you suffer from more than one (comorbid) condition?
As an example, many people go to the doctor’s seeking to use cannabis to help with something like irritable bowel syndrome (IBS) and, by the end of the appointment, mention they also suffer from depression. This problem proliferates all medicine, not just the medical cannabis world.
Perhaps two of the most common comorbid conditions are anxiety and depression. Many research studies indicate that people who suffer from depression also suffer from anxiety.
Anecdotally, we’ve observed certain patterns in preference that those who suffer from depression tend to prefer energizing cannabis strains, while those who suffer from anxiety tend to prefer strains that relax. Yet, a person who suffers from anxiety may want to limit their THC intake, as it can trigger anxiety in high doses.
Bearing all this in mind, the anxious-depressive will likely need the THC for mood elevation in order to combat depression, but be aware that too much THC may trigger anxiety. Learning how to “balance” the THC with CBD and other cannabinoids seems to be key.
One solution for someone with comorbid anxiety and depression? Microdosing a small amount of THC via tincture or edible (say, around 3 mg), or taking the dose in a vape pen for situations when more immediate relief is needed (e.g. a sudden anxiety attack). Another option would be to try and find Sativa/indica hybrids in the right ratio to help with both disorders.
We can use a similar line of thinking with other comorbid conditions, where microdosing a therapeutic level allows users to slowly find the dose where they’re most comfortable. A total of 2.5 mg of cannabinoids may be a good place to start.
2. The difference between strain names, indicas vs. sativas, and cannabinoid content
At this point, it is worth asking, “What precisely makes a particular strain what it is?” To try and break down what is a complicated subject matter, keep the following in mind:
Rather than trying to think “what strain do I need for which condition?”, look instead at the measurement of cannabinoid-terpenoid ratios. Strains can have the same name and entirely different ratios, and lab test results are a better indication of effect.
Touching on the indica vs. sativa debate, while these names refer only to the characteristics of the plants’ growth, we do see some patterns across their cannabinoid and terpene profiles, but these are not strong correlations. Indicas from the Afghani region generally do (but not necessarily always) contain more CBD (as well as terpenes such as myrcene) than sativas from Equatorial regions. Sativas from equatorial regions, meanwhile, seem to generally contain more tetrahydrocannabivarin (THCV) than indicas, and often contain terpenes such as terpinolene, limonene and beta-caryophyllene. Alpha- and beta-pinene seem to be present in both types of cannabis to varying extents. Ruderalis plants have often been tested to have high amounts of CBD.
Decades of industry hybridization have blurred the lines between cannabis varietals, meaning that the same genotype can express distinct phenotypes with their own cannabinoid-terpenoid ratios. Certain strains may contain very unique and beneficial cannabinoids. Remember, depending on how you count them, there are around 150 different identified cannabinoids/sub-cannabinoids, around 212 terpenes and 20 flavonoids in the cannabis plant.
Different growing environments and conditions will affect what ratios are expressed in the plant. Measuring all of them accurately in a plant that expresses high amounts of variation is extremely difficult. The effect that each one can also differ from person-to-person, and THC/THCA content alone won’t determine how psychoactive a varietal of cannabis is.
On the whole, it would seem that there is little difference between sativas and indicas, and that the strain names are generally meaningless. In fact, even the term “strain” in relation to cannabis is inaccurate, as “strain” is a term used for bacteria and viruses, not plants. Different types of cannabis created by different breeders are more appropriately called “cultivars”. The unique cannabinoid and terpene profile each type of cannabis contains is better known as a “chemotype”.
However, other studies have found that some patterns do exist between different varieties of cannabis, and that the names of specific cannabis varieties by specific breeders does correlate somewhat with the terpene profile. Landrace cannabis varieties (distinct types of cannabis grown in specific regions of the world, without hybridization) may contain different and distinct cannabinoid profiles, and potentially more CBD. However, this is not a hard-and-fast rule, and the environment a cannabis plant was grown in (i.e. amount of sunlight, type of soil, altitude, humidity etc.) can impact the cannabinoid-terpene-flavonoid profile a plant ultimately ends up expressing.
To reiterate: different people suffering from different conditions are likely to require different cannabinoid-terpenoid ratios and dosages. There may be patterns regarding condition and commonalities in physiology, but overall, everyone has a unique ECS, and to which degree there is a difference remains unknown. Age, height, weight, gender, diet, activity levels and many other factors influence what effect cannabis has. The name of a product or variety of cannabis alone will not necessarily give you an indication of the sort of effect it has – only the ratio and combination of cannabinoids, terpenes and flavonoids will, and even then it will be highly individualized.
3. Are you taking any other medications alongside cannabis?
CBD inhibits a liver enzyme, cytochrome P450, which metabolizes many prescription drugs. In fact, over 50% of drugs are metabolized via the cytochrome P450 and other CYP enzyme pathways. THC and CBN are thought to desensitize cytochrome P450 as well, but to a lesser extent than CBD. By inhibiting these enzymes, the effects of these medications can either lessen or be greatly increased with a longer duration. In general, medical cannabis has been shown to interact with these drugs and medications more than most others:
- Opioids like tramadol and oxycodone
- Benzodiazepines like alprazolam and carbamezipine
- Blood thinners like warfarin
- Some types of antidepressants, particularly duloxetine (Cymbalta) tricyclic antidepressants (TCAs) like amitriptyline and doxepin
- Antihistamines like diphenhydramine (Benadryl)
- Alcohol
This means that care must be taken if other pharmaceutical drugs are used in combination with cannabis, though cannabis may, in turn, allow patients to lessen their dependence on these medications. For example, a person who is suffering from epilepsy may need to taper the amount of AEDs they need to take, or someone suffering from chronic pain may be able to reduce or replace their prescription opioids.
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4. What do I hope to achieve with the help of cannabis?
Do you want to be able to walk a mile? Do you want to be able to walk around during the day without a cloud over your head? Do you want to be able to sleep or eat properly? A clear wellness goal will help you figure out the best dosing strategy for your needs.
5. Remember, everyone’s endocannabinoid system (ECS) is different.
Some people may need high doses of a particular cannabinoid or set of cannabinoids to achieve the same results with the same condition. Moreover, as everyone has a different endocannabinoid system, what works for one person may not work for another. Although it’s definitely worth asking about others’ preferences, it’s more important to find your own therapeutic range.
Although everyone has a different ECS, we can make some generalizations. The patient’s age makes a difference: younger people may be more prone to the negative effects of THC, whereas older people may benefit from a small dose of THC. Due to hormonal differences, women may also be more sensitive (as well as potentially more tolerant) to the effects of THC. Diet and lifestyle factors may also make a difference in the effect cannabis may have.
6. Starting with a wide range of cannabinoids and terpenes may be best.
Anecdotally, some of the most popular strains (cultivars) have very wide terpene profiles.
The cannabis plant, just like the human body, has its own checks and balances. Should one particular compound overproduce, another compound will be released to mitigate the effects of the other.
Choosing a strain with a wide terpene and cannabinoid profile may help mitigate the negative effects of other compounds. Again, much of this is condition-dependent, but it is a concept worth remembering when hunting for a particular cannabinoid.
We must be careful of stating that a strain (e.g. Blue Dream) will definitely contain these terpenoids and cannabinoids, every time Yes, some strains of cannabis follow certain patterns, but this can change significantly over time with generational breeding. Even cannabis plants that are reproduced asexually can differ, as mutations arise.”
Growing the same genetics in a different environment can also affect the cannabinoids and terpenes it contains. The cannabinoid-terpenoid profile of a cannabis plant also depends upon when it was harvested during its flowering cycle – it makes a difference if a plant was harvested at nine weeks or ten weeks.
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7. Don’t forget the acidic cannabinoids, like THCA and CBDA.
These molecules are the acidic, non-decarboxylated precursors to THC and CBD: tetrahydrocannabinolic acid (THCA) and cannabidiolic acid (CBDA). “Decarboxylation” refers to the loss of a carbon dioxide (CO2) molecule. Losing CO2 via light, heat or pressure converts THCA into THC and CBDA into CBD.
THCA and CBDA work synergistically with other cannabinoids and increase their therapeutic effects by several magnitudes. THCA combined with CBD, for example, may have significant anti-inflammatory properties – more than just using one or the other alone.
Also, acidic cannabinoids are often very volatile, meaning heat, light, and air will convert them into THC, CBD, etc., and degrade them over time. This means that the only feasible way for patients to consume these compounds is to ingest whole plant preparations that have not been extracted using heat. High-quality, tested ethanol extractions, oil extractions, and pressure extractions are likely best to preserve these cannabinoids for medically-minded people.
Although there is some debate around how useful the acidic cannabinoids are and how active they are in the body, some evidence suggests that they have their uses, such as showing that cannabinoids like CBDA have significant anti-inflammatory properties.
8. On “cannabinoid hunting”.
We often see the marketing machine go into overdrive, and certain cannabinoids and terpenoids become the flavor of the month. CBD is perhaps the biggest example of this, and many people say they only want CBD without any THC. This is an unscientific way of going about things, like some people, for example, those who suffer from cancer or neurological conditions such as multiple sclerosis may need THC in order to beat pain and/or spasms.
Also, without the THC, the CBD generally doesn’t do as good a job. CBD is a powerful antiemetic. Combine it with a little THC and CBDA, and the CBD becomes an even more powerful antiemetic with fewer side effects. For a person with ADD/ADHD, a sativa with THC and terpenes like limonene, pinene, and beta-caryophyllene may be helpful, although those who are prone to anxiety may wish to give such a profile a wide berth. Resist good marketing, and pay no heed to those who speak ill of THC or any other cannabinoid or terpene. The entourage effect is very real.
Yet, for all the problems associated with “hunting” for specific cannabinoids and terpenoids, some conditions do respond best to certain profiles. We do not yet know precisely which profile is best for which condition, but we’ve recognized some patterns.
The following table will hopefully illustrate these patterns, but please be warned that this is more theoretical and based upon observation rather than any definitive clinical evidence. We recommend taking any advice on strains with a pinch of salt, but we hope this provides a good starting point.
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9. When are you using medical cannabis?
Many patients will want to keep awake and have their wits about them during the day, and will likely want to avoid too much THC. Conversely, at nighttime, THC, linalool, and myrcene may be more helpful to combat insomnia (high amounts of CBD can actually help many people keep awake).
As an example, some patients may use a CBD:THC ratio of 3:1 during the day, and then a 1:3 ratio at night in order to help them sleep. The terpenoids matter, too: where limonene and beta-caryophyllene may promote wakefulness in combination with THC and CBD, linalool and myrcene may promote restfulness in combination with THC and CBD.
10. Remember: not all products are the same!
Think that all 3:1 CBD:THC preparations (or indeed any other ratio) are the same? Not quite: different extraction methods will likely have different effects, making a 3:1 CBD:THC ratio from one company will vary quite significantly from another company’s preparation. Both companies will likely be using different plants to make their products, adding or subtracting other cannabinoids and terpenoids from the preparation, on top of any differences in extraction technique.
With tinctures specifically, the carrier oil used as a base will affect absorption rate to some extent, too. Olive oil and MCT oil are the usual choices, due to them being more readily absorbed by the body and their potential health benefits.
Ingestion methods also vary widely in their results, even with the same ratio of cannabinoids. Remember: eating cannabis can be more powerful than vaping, and tinctures can be similar in strength to edibles. Microdosing tinctures & edibles is ideal for longer-term relief, while vapes can provide more immediate relief. You can learn how to make your own cannabis oil or cannabutter here and check out more about the pros and cons of each ingestion method here.
Always remember: cannabinoids are “biphasic.”
This means that cannabinoids can have different effects in different dosages.
- CBD can be energizing in low doses, and sedative in higher doses. CBG may behave similarly.
- THCV has antipsychoactive effects in low doses, and psychoactive effects in higher doses.
- THC has anti-depressant and anxiolytic (anti-anxiety) effects in low doses, but can prompt anxiety and paranoia in higher doses.
- Different terpene combinations may also make a difference. Cannabis varieties high in myrcene, linalool and humulene, combined with THC tend to be more sedative. Cannabis varieties containing less myrcene and more limonene, terpinolene, pinene and beta-caryophyllene, with more moderate THC levels and low levels of CBG tend to be described as being more uplifting.
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Although we cannot provide definitive advice on what type of cannabis or what cannabinoid profile may be best for you, both scientifically and legally, we hope this information provides a useful framework for self-discernment. Start slow and low, and work to a level where you feel most comfortable without necessarily being too intoxicated.
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