Accurate Education - Marijuana (Cannabis): Dosing

Marijuana (Cannabis):

Dosing

The use of marijuana for medical purposes remains highly controversial and is compromised by a lack of good quality evidence regarding the specifics of clinical effectiveness and the details of treatment including dosing frequency, amount and duration. The following information is provided as an introduction to what is believed to be true about medical uses of marijuana. There will surely be more information to come.

The emphasis regarding dosing of “medical marijuana” on this site is focused on the products legally available in Louisiana and are based in part on recommendations provided by the manufacturers of cannabis-based products produced from Louisiana-grown marijuana. Additionally, recent recommendation regarding dosing have been published (2021) based on the Delphi method. The Delphi method is a “structured communication technique that has been developed as a systematic, interactive forecasting method” based on a consensus of opinions of experts with years of experience in their fields, in this case the use of marijuana for medical purposes. While consensus processes like the Delphi method are well-meaning, they are not a substitute for rigorous research with large sample sizes, adequate duration, and standardized outcome measures. Unfortunately, such research remains lacking.

Many medical journal publications are referenced on the bottom of this page as well as elsewhere on this web site that explore clinical therapeutics and dosing of cannabis-based products otherwise available outside of Louisiana.

Links to other Pertinent Educational Pages:

Links to ALL Marijuana Educational Pages

Use and Dosing

Marijuana (Cannabis):

Key to Links:

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Red text – another page on this website
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The medical information on this site is provided as a resource for information only, and is not to be used or relied upon for any diagnostic or treatment purposes and is not intended to create any patient-physician relationship. Readers are advised to seek professional guidance regarding the diagnosis and treatment of their medical concerns.

Marijuana Dosing – An Overview

As noted in the introductory marijuana (cannabis) medical use overview, our current understanding of medical uses of cannabis is limited, based on only a rudimentary beginning of research. The nature of the research currently available to the medical community that can direct clinicians toward safe and effective therapeutic applications of cannabis is very limited and based mostly on observational studies to guide cannabis prescribing. Cannabis compounds may have biphasic properties, meaning that low and high doses of the same substance can produce opposite effects. “Less is more” is often the best advice with respect to cannabis initiation. Because of this state of knowledge, dosing recommendations are also compromised. As such, the best rule for dosing cannabis products is to “Start low, Go slow.”

Most importantly, it needs to be emphasized that humans show high inter/intra-individual variability in absorption of cannabinoids, especially with oral and sublingual/buccal administration. This means both from one person to another as well as within the same person at different times and circumstances there will be a wide range of differences in how much cannabinoids will be absorbed.

Also, it is important to remember that dosing for one condition will not necessarily be the same for a different condition. For example, the dose of Δ9-THC to stimulate appetite is different than the dose to treat nausea associated with chemotherapy. Furthermore, the dose to treat pain is still different and may vary even more depending on the type and location of pain.

In addition to the strength of dosing (number of milligrams), an important variable in determining dosing with cannabis-basesd products is the balance or ratio of the constituents, particularly Δ9-THC (THC) and CBD. It has been established that the ratio of THC to CBD influences the clinical benefit as well as the likelihood and severity of side effects. Ultimately, however, the final determination of optimal dosing will be individually determined for each patient and initially will likely require trial and error dosing. The inexperienced, novice user must start at a low dose and proceed to increase their dose slowly to avoid undesirable side effects. In general, the recommended dosing limit for THC is 30 mg/day unless otherwise advised by recommending physician.

General THC Dosing Guidelines for the Initial Use:

- Up to 2.5mg: One may may feel the desired relief.
- 6 – 15mg: Euphoria and impaired coordination may occur.
- 16 –30mg: Extremely high dose for novice patient. Experienced patients may feel altered perception. This level may result in negative side effects for patients with low THC tolerance.
- 31 –50mg: Only for very experienced patients. Patients may experience side effects like paranoia, sweating, and increased heart rate.
- 51+mg: Dangerous for novice patients and any patient with low to moderate THC tolerance. May lead to hallucinations.

At this stage of our clinical understanding and limited product availability, dosing recommendations are based largely on THC and CBD content as well as the type of product (tincture vs vape) and method of use (oral, sublingual or vaped). The missing link here is the lack of knowledge regarding the third pillar of therapeutic contribution to cannabis-based products, the terpenes. Terpenes are the aromatic constituents that contribute to the aroma of cannabis but they are also important contributors to the therapeutic benefits of cannabis products. They also may contribute to the side effects of a product, especially sedation, and dosing may need to be adjusted based on terpene benefits and side effects.

See: Terpenes

So, the clinical effects of marijuana come from not just THC and CBD, but they are determined by both the concentrations and ratios of these two constituents as well as influences from the many other cannabinoids and terpenes found in the plant.

General recommendations can be made but each individual should tailor dosing to meet their specific needs based on their personal responses to the cannabinoids including therapeutic benefits and adverse side effects. There are many variables that come into play regarding dosing, including genetic variants in cannabinoid metabolism and drug interactions.

Dosing – Important Considerations

It often requires some degree of trial and error to establish optimal dosing with cannabinoids, with optimal dosing defined as the lowest dose with the maximum benefit and no side effects.

Potential for Side Effects

Due to the greater potential for adverse side effects with THC compared with CBD, it is generally wise to also start with lower ratios of THC to CBD. That is, initiate use of cannabis products with greater amounts of CBD than THC. Due to expected side effects such as sedation, cannabis-based products should be started at night prior to going to sleep. For those who feel activated by cannabis-based products, morning dosing should be initiated. Cannabis should be utilized with caution or avoided in unstable cardiac conditions, such as angina, due to potential for rapid heart rates and drop in blood pressure due to THC, but there are no QTc issues.

Route of Administration

Cannabis-based products can be placed under the tongue (subingual), in the buccal space adjacent to the gums and cheeks (buccal), inhaled, or taken orally as capsules or lozenges and swallowed. The onset and duration of action of a product will vary depending on which route is employed.

Bioavailability

The “bioavailability” of a medication is the measure of how effectively administration of that medicine achieves blood levels. As a standard of definition, the bioavailability of a medication given directly intravenously is 100%. Other forms of administration, such as smoking, eating and application to skin, will be associated with less bioavailability. Bioavailability is generally described in terms of maximum time in the blood (Cmax) and maximum overall absorption into the blood (AUC – Area under the Curve). Tmax is the time necessary to reach the maximum blood concentration after administration of a medication.

Bioavailability is the degree and rate at which a substance is absorbed into the blood where it can be delivered to the organ systems necessary for therapeutic effects. The greater the bioavailability, the less product needs to be consumed to achieve a therapeutic effect. Bioavailability of cannabis products varies somewhat from individual to individual and is determined mostly by how it is consumed, including if it is ingested with food. It is also affected by the individual’s age, general health and the presence of gastrointestinal disorders. As a general guide based on method of use, the bioavailability of cannabis is:

- Smoking: 25-30% bioavailability (Reports vary from 2-56%)
- Vaporization: 30-60% bioavailability
- Tinctures (sublingual): 40-50% bioavailability
- Edibles: 5-12% bioavailability (Reports vary from 4-20%)

Translating bioavailability to determine a dose:

Smoking

An average joint is reported to generally contain about 300 mg of flower. If the flower contains 20% THC, then a joint would contain about 20% of 300 mg, or 60 mg of THC. With the reported bioavailability of smoking to be 25-30%, then smoking the entire joint would deliver 15-18 mg of THC to the blood.

Vaping

A vaping device for flower holds up to 300 mg of flower in its chamber. If the flower contains 20% THC, then a chamber would contain about 20% of 300 mg, or 60 mg of THC. With the reported bioavailability of vaping to be 30-60%, then vaping the entire chamber would deliver 18-36 mg of THC to the blood.

Tincture (Oromucosal/Sublingual)

Tinctures are sold as containing 150 mg, 300 mg, 600 mg or 900 mg of liquid tincture in a 30 ml bottle. A 30 ml bottle containing 300 mg of THC would contain 10 mg/ml. Each full dropper contains about 1 ml, or 10 mg of THC. If 1 ml (or 10 mg of THC) is held under the tongue for 1-10 minutes, based on the reported bioavailability of 40-50%, then 4-5 mg of THC would be delivered to the blood.

Edibles

The bioavailability of ingested THC will vary widely based on whether it is ingested with food which, although it slows absorption of THC somewhat, enhances total absorption. Ingesting cannabinoids with a moderate to high-fat meal can enhance intestinal lymphatic transport and markedly increase systemic bioavailability.

THC and CBD are both rapidly absorbed in the fasting condition, reaching their peak plasma concentrations at about 1.5 hours, compared to fed conditions, about 4 hours after dosing. However, the presence of food enhances absorption, so more cannabinoids are absorbed. Absorption is 2.8-fold higher for THC and 4.1-fold higher for CBD after a meal.

Given the reported bioavailability of edible THC of 5-12%, ingesting 10 mg of THC would deliver 0.5 t0 1.2 mg of THC to the blood, depending of fasting or fed condition.

To determine actual dosing of THC and/or CBD, it will depend on the product and route of administration – see specific product for dosing particulars.

(1) Sublingual and buccal products are fast-acting (10-30 minutes to onset of maximum effect) and will sustain their activity to a moderate degree. Because sublingual and buccal preparations will also be swallowed with saliva, they do share limited properties of oral, swallowed products. The consensus of opinion is that one should hold the tincture under the tongue for 1-2 minutes to provide optimal absorption. While sublingual/buccal (oromucosal) administration circumvents some of the problems associated with the oral route, and provides a more rapid onset of action, research suggests that a substantial proportion of the oromucosal delivered dose is actually absorbed by the GI tract.

(2) Inhaled, or vaped, products provided by metered-dose inhalers (MDIs) have the fastest onset of action (5-10 minutes to onset of maximum effect) but the shortest time of activity. The safety of vaped products has recently come under scrutiny due to users developing serious pulmonary complications including death. The circumstances appear to suggest the problem may come from additives to the products but definitive answers to the underlying cause remain elusive. Caution is advised, particularly to avoid vaping products with Propylene Glycol.

See: Marijuana – Inhaled (Smoked and Vaporized) & Dosing: Flower vs Pharmaceutical

(3) Orally swallowed products have the slowest onset of action (1-3 hours to onset of maximum effect) but the longest time of activity. Both THC and CBD are lipophilic molecules meaning they dissolve well in fat but not water. This characteristic slows and limits their absorption from the gut. However, absorption will be increased substantially overall if they are ingested with or after eating foods containing fats or oils. The presence of fats or oils in the gut stimulate the release of bile salts into the gut that facilitate absorption of fatty compounds, including THC and CBD. Therefore, although total absorption will be enhanced in the presence of food in the gut by as much as 25%, the absorption and therapeutic response will be slower.

While being absorbed from the gut, THC and CBD are initially metabolized by CYP enzymes in the intestine and then will pass through the liver before reaching the blood stream to achieve their effects. Passing through the liver allows THC and CBD to be further metabolized and these breakdown products, or metabolites, provide their own therapeutic effects and side effects.

THC will be partially metabolized into 11-hydroxy THC, a metabolite that shares at least some of the effects of THC including the psychoactive effects of feeling high and euphoric. Research suggests that 11-hydroxy THC may also have a stronger impact than THC relative to the “high” (and also other therapeutic benefits of THC?). Thus oral products may offer different therapeutic effects as well as different side effects than the same product used sublingually (oromucosal) or inhaled.

See: Marijuana (Cannabis) – Oral Use (Edibles)

Tolerance to Cannabinoids

As with opioids, the degree of a patient’s tolerance to cannabinoids will be an important variable in establishing the optimal dose. For those patients with a long established history of marijuana use there may be significant tolerance to the therapeutic effects of cannabinoids which may require higher doses to achieve benefit. Those individuals without previous exposure to marijuana or cannabinoids will be expected to have minimal tolerance and should be started at lower doses.

Dosing – General Strategies

Cannabis initiation: ‘start low, go slow, and stay low’.
THC-related side effects such as anxiety, fatigue, tachycardia and dizziness are avoidable when starting dose is low and titration is slow
Medical cannabis patients treating chronic conditions/symptoms should start with oral tincture preparations which are longer-acting and with a CBD-balanced or CBD-dominant formulation with the smallest amount of THC to get the greatest improvement in symptom control, function, and quality of life, with fewer adverse events.
When pain is not well controlled it may be necessary to increase the THC dose and confirm at least as much CBD as THC, reassess terpenes.
When anxiety or insomnia is not well controlled, increase the CBD and terpenes.
Getting euphoric effects or a “high” is not required to get symptom control.
Because CBD can reduce THC side effects, CBD-dominant preparations have fewer unwanted psychotropic effects but may require higher dosing, sometimes up to 300 mg of CBD/day.
Dosing with cannabis products with balanced THC:CBD @ 1:1 ratios may be guided by established dosing with Sativex, a pharmaceutical product approved for use and widely prescribed in Canada and Europe as well as >100 countries. Sativex contains 2.7mg THC/2.5mg CBD per 0.1 ml spray and has a maximum recommended dose of 32.4mg/30mg/day. A large body of guiding recommendations of therapeutic benefits from cannabinoids is based on studies incorporating Sativex.
Tolerance does not develop to most benefits so dose escalation over time is not generally seen.
Starting doses of THC should be 1-2 mg, initiated at bedtime to reduce side effects. Higher starting doses should be limited to those with current cannabinoid use experience.
THC dosing should be increased slowly, every week as needed for those beginning cannabis products. For those with more experience, doses can be increased every 2-3 days and/or increase frequency of daily use to 2-3 times/day, generally up to 15 mg/day.
THC doses higher than 20-30 mg/day are generally not needed or recommended. For those who appear to have high tolerance to THC requiring doses higher than 30 mg/day, a cannabinoid “reset” or sensitization protocol is recommended. See “Cannabinoid Sensitization Protocol.“

Dosing – Delphi Recommendations (2021)

In the 2021 issue of Journal of Cannabis Research, a multidisciplinary group of global experts in the field of cannabinoids published a modified Delphi process that developed three protocols for the dosing and administration of cannabinoids to treat patients with chronic neuropathic, inflammatory, nociceptive, and mixed pain. Three treatment protocols were developed — conservative, routine and rapid — which were designed based upon the desired time to achieve clinical effects. In the conservative and routine protocols, CBD-dominant cannabis products are started initially whereas in the rapid protocol, patients are started on a cannabis product with THC and CBD in a 1:1 balanced ratio.

Conservative Protocol

The conservative protocol allows for a slow introduction and increase of THC after initiation of a CBD-dominant cannabis product. In the conservative protocol, the patient is initiated on a CBD-dominant cannabis product at a dose of 5 mg CBD once daily and the CBD dose is titrated up by 10 mg every 2 to 3 days until the patient reaches their goals, or they reach 40 mg CBD/day. If the clinical response remains inadequate at 40 mg CBD/day, THC is started at 1 mg/day and titrated up by 1 mg every 7 days as needed until a maximum daily dose of 40 mg/day of THC.

Routine Protocol

The routine protocol allows for a faster introduction and increase of THC after initiation of a CBD-dominant cannabis product. As in the conservative protocol, in the routine protocol the patient is also initiated on a CBD-dominant cannabis product at a dose of 5 mg CBD once daily and the CBD dose is titrated up by 10 mg every 2 to 3 days until the patient reaches their goals, or they reach 40 mg CBD/day. If the clinical response remains inadequate at 40 mg CBD/day, THC is started at 2.5 mg and titrated up by 2.5 mg every 2 to 7 days until a maximum daily dose of 40 mg/day of THC.

Rapid Protocol

In the rapid protocol, patients are started on a THC and CBD product with a 1:1 ratio, at 2.5–5 mg of each cannabinoid, 1-2 times daily and then titrated up as needed by 2.5–5 mg of each cannabinoid every 2 to 3 days until the patient reaches his/her goals or to a maximum THC dose of 40 mg/day.

Dosing – Individual Cannabinoids

Emphasizing the need to individualize dosing based on both a patients response and the condition treated, some general recommendations can be provided to allow some context and direction when determining appropriate dosing.

Dosing – CBD (Cannabidiol)

See:Cannabidiol (CBD) – Introduction & CBD Pharmacokinetics

CBD does not produce the mind-altering “high” effects like euphoria but it does reduce anxiety and enhance sleep. It has anti-inflammatory and analgesic properties, operating through numerous distinct mechanisms. It also has anti-convulsant, anti-psychotic, antioxidant, neuroprotective and immuno-modulatory effects. CBD is also thought to reduce nausea, particularly related to chemotherapy.

Additionally, CBD may enhance the benefits of THC, especially for pain and it may reduce the side effects of THC as well, especially anxiety.

CBD products are available as CBD only (CBD Isolates) or CBD in combination with varieties of other constituents, some cannabis-based like terpenes but others with non-cannabis based nutriceuticals. Of course, some CBD products have THC (<0.3% if legal, OTC products) or significant amount of THC (controlled substances requiring a physician recommendation/prescription). Due to the variability of CBD products and their constituents including terpenes, dosing recommendations will depend on the individual product.

CBD – Anxiety

For anxiety, CBD products are recommended to be started at a dose of CBD 5 mg twice daily and titrated up to CBD 40 mg daily, although in some clinical trials effective CBD doses ranged up to 500 mg milligrams/day.

CBD – Pain

CBD alone has been shown to be effective in patients with pain from neurologic injuries, kidney transplantation, neuropathy and fibromyalgia. Dosing of CBD for pain is also started at 5 mg twice daily and titrated to 40 mg daily, although again in some clinical trials CBD doses ranged up to several hundred milligrams or more. However, when treating pain and the CBD dose alone is ineffective at 40 mg/day, THC should generally be added starting with small doses, 1-2 mg for marijuana-naive patients. When treating pain the combination of CBD with THC is generally more effective and CBD also reduces some of the side effects of THC, including THC-induced anxiety. In general, when combining THC with CBD, the CBD is recommended to be at a higher dose than THC at least to start with.

Dosing – THC (Tetrahydrocannabinol)

THC is responsible for many of the therapeutic effects of marijuana, including the analgesic, anti-spasmodic, anti-tremor, anti-inflammatory, appetite stimulant and anti-nausea properties. THC and its active metabolite, 11-Hydroxy-THC also produce the “high” or euphoria associated with use of marijuana. Because of the complementary benefits provided by CBD along with its potential for reducing side effects of THC, THC is not usually initiated alone but in combination with CBD, generally after CBD has first been titrated up to doses of 20-40 mg/day.

The dosing of THC generally starts low in the marijuana-naive individual, beginning with a dose of 1-3 mg/day and titrated up by 1-3 mg every 3-7 days as needed until a maximum daily dose of 40 mg/day of THC.

See: THC Pharmacokinetics

Dosing – CBD in Combination with THC, CBD:THC Dosing Ratios

As noted above, not just the total amount of THC and CBD are important factors in dosing but also the ratio of these two constituents with one another. While specifics remain unknown as to ratio dosing, some generalities have been suggested.

The caveat “Start low, Go slow” applies when initiating treatment iwth CBD and THC. Due to the greater potential for adverse side effects with THC compared with CBD, it is generally wise to also start with lower ratios of THC to CBD. That is, initiate use of cannabis products with greater amounts of CBD than THC. A patient’s sensitivity to THC is a key factor in determining the ratio and dosage of CBD-THC products. While some people can enjoy the cannabis high and consume reasonable doses of cannabis without feeling too high, dysphoric or becoming dysfunctional, others find THC unpleasant and intolerable. THC-related side effects can include anxiety, sedation, palpitations (tachycardia), risk of cannabis-use disorder (addiction), psychosis and syncope (blackout).

While definitive research is needed, some generalizations regarding optimal ratios of CBD to THC have been proposed regarding therapeutic benefits:

20:1 CBD to THC

Targets Neurological issues:

- Anxiety
- Cerebral Palsy
- Depression
- Epilepsy
- Mild Arthritis
- Parkinson’s
- Restless Leg Syndrome
- Phantom Pain
- Autism

3:1 CBD to THC

Targets Immune Conditions:

- Auto-Immune Diseases
- Breast Cancer
- Crohn’s Disease / Colitis
- Extreme Arthritis
- Irritable Bowel Syndrome
- Multiple Sclerosis
- Pain and inflammation
- Psoriasis

1:1 CBD to THC

Much of the research surrounding THC:CBD ratios of 1:1 are based on GW Pharmaceuticals‘ prescription medication, Sativex, which has a 1:1 ratio of THC and CBD. Research concluded that this balanced 1:1 formulation is the most effective ratio across all categories of sleep, pain control, and muscle spasms. Extensive clinical research has shown that a 1:1 THC:CBD ratio is most effective for neuropathic pain. For neurological disease and many other ailments, patients may benefit from a balanced ratio of CBD and THC.

Targets pain, certain cancers and helps other issues:

- Appetite Stimulation
- Autism
- Certain Cancers
- Fibromyalgia
- Severe Pain
- Skin Conditions Applied Topically: Skin Cancer, Psoriasis

Low CBD:THC (THC-rich Formulations)

Conditions that may respond better to THC-rich formulations include Crohns, PTSD, glaucoma, HIV and other conditions of cachexia (wasting syndromes), Parkinson’s and chemotherapy-induced nausea and vomiting. In most cases, however, a THC-isolate formulation (THC only) is not recommended as the sole formulation due to the greater risk for side effects and the lack of entourage effect/synergistic benefit. When higher THC doses are required due to tolerance, it is recommended to supplement THC-isolate formulations with a broad spectrum or full spectrum CBD product, titrating their ratios based on individual needs.

Dosing – New Medical Products

Due to the challenges of poor bioavailability and poor oral absorption with CBD, research is progressing to develop CBD medicines with better absorption profiles. New approaches include self-emulsifying drug delivery systems, improved single crystal structures, and CBD cocrystals.

Self-Emulsifying Drug Delivery Systems (SEDDS)

Methods now becoming available that increase oral CBD bioavailability include self-emulsifying drug delivery systems (SEDDS). SEDDS involve mixtures of oils, surfactants, and solvents that produce “nano” or micro sized droplets when they come into contact with an aqueous solution such as in the gut. The small nature of the droplets increases the surface area available for drugs to be dissolved and absorbed. Self-nanoemulsifying technology has demonstrated greater bioavailability (about one-third higher compared to conventional oromucosal spray), greater solubility, and faster time to peak plasma concentrations, although inter-individual variations are still high.

Dosing – Individual Products

Dosing – Tincture Products

The cannabis-based tincture products currently available in Louisiana differ by their concentrations and ratios of THC to CBD., with the specific amounts of other cannabinoids and terpenes unknown. Each of the tincture products are dispensed in 30 mL bottles with a 1 ml dropper designed to provide dosing of the medication in increments of 0.1 – 1 ml. For specific tincture related dosing, See: Marijuana Products – Tinctures

Dosing – Vape Products

Currently the vape products available in LA are extremely limited in their constituent profiles of THC and CBD. The products include either self-contained cartridges or RSO cartridges that are filled manually before use.

The self-contained cartridges only include one product with significant CBD, the “Freedom” vape that has a balanced formulation of THC & CBD with 250 mg each of THC and CBD per cartridge. The other self-contained cartridges have a little more than 400 mg THC and no CBD per cartridge and all self-contained cartridges have different, incompletely specified, terpene profiles.

The RSO products each have more than 700 mg THC per cartridge and none of them have significant amounts of CBD. Each RSO product has different, incompletely specified, terpene profiles.

See: Marijuana Products: Vape Products

Dosing – Dried Cannabis

See: Marijuana – Inhaled (Smoked and Vaporized)

The determination of dosing is one of the major stumbling blocks in the study of medical marijuana. This is because marijuana, a plant, varies widely in the amount and ratios of the pharmacologically active constituents present depending on a multitude of variables. Depending on the plant there may be over 100 pharmacologically active constituents all of which vary depending on the genetics of the plant, the conditions in which the plant was grown, how and when it was harvested and other variables. As such there is a huge variability in the potency and expected effects between different plants.

As noted above, the major pharmacologically active cannabinoids in marijuana are THC and cannabidiol (CBD). The average contents of THC and CBD in dried plant preparations of marijuana confiscated from 1993 to 2008 in the United States were 4.5% and 0.4%, respectively, although these contents vary widely. In the last decade these percentages have increased in different strains to more than 3-5 times as potent.

Calculating the dose of THC and/or CBD of smoking cannabis plant is at best is inaccurate but nevertheless, estimates can be made.

See: Marijuana Dosing – “Pot (weed)” vs. Pharmaceutical Products

Smoking a “Joint”

With respect to smoking pot in the form of a joint, research indicates the average amount of marijuana plant in a joint is 0.3 to 0.6 gms, with experienced users tending toward the higher amount. Obviously, if one roll thin “needles” or fat “hoagies,” one should adjust this estimate. In assessing the THC content of contemporary pot, the percentage of THC in the pot ranges from very low (<5%), to low (5-10%), moderate or “good pot” (10-15%), strong (15-20%) and very strong (>20%). Most patients use 1–3 g of herbal cannabis per day, whereas < 5% of patients use > 5 g per day. It should be noted that research indicates people tend to overestimate the amount of marijuanas they use, even regular and heavy users tend to overestimate their use of flower by 30% and their estimates of use in joints is overestimated by as much as 137%. Tolerance may develop to the benefits and over time dose escalation may be observed.

It is estimated as a ballpark figure that for each percentage of THC in the pot, smoking an average joint would be dose equivalent to 1 mg of THC for each percent THC in the marijuana. In other words, smoking an average joint of 1% THC pot (weak pot) would deliver a 1 mg dose of THC and smoking an average joint of 10% THC pot (average pot) would deliver a 10 mg dose of THC and smoking an average joint of 15% THC pot (strong pot) would deliver a 15 mg dose of THC. This estimate would be dependent also on how deep one inhales and how long one holds their inhalation before exhaling.

Smoking a “Bowl”

Smoking a “bowl” in a pipe or bong would equate to the use of about 0.25 grams, slightly less pot than an average joint. But this method is thought to deliver 10-20% more THC. Thus, one might predict one bowl would deliver 1.2 mg of THC if smoking 1% THC pot (weak pot) or 22 mg if 15% THC pot (good pot).

Dosing – Recommendations for Titrating Cannabinoids and Tapering Opioids for Chronic Pain Control

In patients with chronic pain who are taking opioids but not reaching their therapeutic goals or who are displaying opioid-related complications, cannabinoids may be considered as an alternative treatment. A consensus article published in Canada in 2021 advised initiation with a cannabidiol (CBD)-dominant oral extract in the daytime and adding THC as needed. When adding THC, a starting dose of 0.5-3 mg is recommended, increasing as needed by 1-2 mg once or twice weekly up to 30-40 mg/day. Once the patient reports improvement in function, opioid tapering can be initiated.

The opioid tapering schedule shoulb be started at 5%–10% of the morphine equivalent dose (MED) every 1 to 4 weeks. Clinical “success” ca be defined by an improvement in function/quality of life, a ≥30% reduction in pain intensity, a ≥25% reduction in opioid dose, a reduction in opioid dose to <90 mg MED and/ or reduction in opioid-related adverse events.

Dosing – Other Cannabinoids in Other States and Countries

Canadian Guidelines – 2014

Based on Canadian guidelines published in 2014, smoked cannabis might be indicated for patients with severe neuropathic pain conditions who have not responded to adequate trials of pharmaceutical cannabino
ids and standard analgesics. Smoked cannabis is contraindicated in patients who: (1) are 25 years of age or younger; (2) have a current, past, or strong family history of psychosis; (3) have a current or past cannabis use disorder (marijuana addiction); (4) have a current substance use disorder (addiction to other drugs); (5) have cardiovascular or respiratory disease; or (6) are pregnant or planning to become pregnant. It should be used with caution in patients who smoke tobacco, who are at increased risk of cardiovascular disease, who have anxiety or mood disorders, or who are taking high doses of opioids or benzodiazepines.

Based on these Canadian guidelines, when smoking is advised (which it is generally not), initial dosing recommendations for smoked marijuana are usually for small amounts of lower-potency marijuana. For example, the starting recommended dosing is 1 inhalation of a 9% maximum THC “joint” once per day. This can be increased to a maximum recommended dose of 1 inhalation 4 times a day, resulting in approximately half a “joint” per day (or 400 mg). Patients should not operate dangerous equipment or perform potentially dangerous activities after use. This includes no driving for at least 3 to 4 hours after inhaled medical marijuana, 6 hours after oral ingestion, and for at least 8 hours if they experience a subjective “high.”

Higher doses are sometimes used. It should be noted that if patients use a 5 gram dose of 15% THC, this represents approximately a 20 times higher dose than the recommended 400 mg of 9% THC. Higher doses, especially at this level are associated with significantly higher risk of adverse side effects (see below). In marijuana resin (commonly referred to as hash or hashish), the average contents of THC, CBD, and CBN are 14.1, 2.5, and 1.9%, respectively. Other commercial products including oils and edibles may contain even higher potencies.

Germany

In Germany currently there are 14 types of cannabis flowers that can be prescribed, with THC concentrations varying between 1% and 22% and CBD concentrations varying between 0.05% and 9%. Dosing information for specific indications is not available but the German Narcotic Drugs Act sets the maximum amount that can be prescribed within a 30-day period at 100 g cannabis in form of flowers, regardless of THC content. While THC-containing capsules and oil are not permitted under the German Narcotic Drugs Act, they can be prescribed for individual therapeutic trials as compounded medications in the form of drops, capsules or inhalation solution. Apparently, their recommended daily doses of THC range between 5 and 30 mg.

Resources:

National Academy of Sciences

The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research

International Cannabinoid Research Society

International Cannabinoid Research Society – Home page

You Tube video marijuana education links:

Cannabis The Evil Weed (2009) part 1 of 16

MediHuanna – Medicinal Cannabis Education for Physicians (July 2018)

Lay-person Websites

These lay-person websites appear to be good resources for exploring medical marijuana. However, as is the case generally regarding medical applications of marijuana and its constitnuents, there is a huge amount of information that is not based in good science and relies on anecdotal (word-of-mouth) evidences. Reader, beware:

References:

Medical Marijuana –Dosing

Medical Marijuana – Tolerance Reversal

www.Healer.com

Medical Marijuana – Prescribing Guidelines

Medical Marijuana – Potential Harms Associated with Cannabis Use

Brief Review of Human Studies Regarding Increased Risk of Harm with Cannabis Use – State of Minnesota – 2016

Medical Marijuana – Driving

Medical Marijuana – Opioids

Medical Marijuana – Opioid Drug Interactions

Medical Marijuana – Pain

Medical Marijuana – Pharmacokinetics

Medical Marijuana – Products

Medical Marijuana – Sleep & Sleep Apnea

Medical Marijuana –Misc

Emphasis on Education

Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.

For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.

Should you wish more information regarding any of the subjects listed – or not listed – here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.

For more information, please contact Accurate Clinic.

Supplements recommended by Dr. Ehlenberger may be purchased commercially online or at Accurate Clinic.

Please read about our statement regarding the sale of products recommended by Dr. Ehlenberger.