Accurate Education – "Medical Marijuana" – Getting Started

Understanding the context of using marijuana and associated products for pain and other conditions

Marijuana (Cannabis)-based Medications for Pain

The recent introduction of marijuana-based products for medical use has coincided with two important developments in the understanding of chronic pain.

First,  the understanding of the role of neuroinflammation (inflammation within the nervous system), along with the role of oxidative stress in the development and maintenance of chronic pain. Most chronic pain is believed to be the consequence of neuroinflammation within the peripheral and central nervous system including the spinal cord and brain. It is this neuroinflammation and oxidative stress that is the target of cannabis-based compounds as well as some other agents including palmitoylethanolamide (PEA), another new “tool in the toolbox.”

In addition, the neuroinflammatory process also plays a role in the way that opioids impact pain including the development of tolerance over time to analgesic benefits of opioids.  Research suggests cannabis-based agents as well as PEA may reduce opioid tolerance and improve the analgesic benefits of opioids by reducing neuroinflammation and by other mechanisms as well. One argument for introducing cannabis-based products for the management of pain is to allow for the possible reduction or avoidance of opioids for pain.

Second, the recent discovery that the Endocannabinoid System (ECS) in mammals is responsible for the therapeutic effects of marijuana, including its role in chronic pain. The primary mechanisms by which marijuana and its constituents engage pain and other benefits are through their interactions with ECS receptors and ECS compounds called “endocannabinoids.” Endocannabinoids are the natural marijuana-like compounds manufactured by the body that have important roles in pain and inflammation.

The Experience of Pain – a complex interplay that includes, mood, memory and emotion

A critical piece of the puzzle of how cannabis improves pain, particularly chronic pain, is understanding that the experience of pain is a complex interplay that includes mood, memory, emotion and other cognitive aspects in addition to simply the pain signals arising from injured tissues and related pain signaling in the peripheral and central nervous system. Because the endocannabinoid system is intimately involved the cognitive components of the pain experience, cannabinoids including THC and CBD significantly impact the experience of pain. As such, the benefits of cannabis products are more often associated with a patient’s improved ability to cope with their pain than any actual reduction in the severity of their pain per se.

Cannabis has also been found to be effective for anxiety, sleep and  muscle spasm. Because there are many therapeutically active constituents in cannabis that contribute to these different benefits, the selection of products and/or formulations should also take into account these other treatment goals in addition to pain relief.

In addition to THC and CBD, terpenes are another group of compounds found in marijuana that are very important contributors to the therapeutic effects of cannabis. In particular, the terpene β-caryophyllene (BCP) is especially important in treating pain and inflammation and should be included with CBD along with other terpenes directed at pain, anxiety, and/or sleep.

Getting Started

It is recommended to begin with the safest agents – those with the least potential for side effects – as well as  the least expensive and easiest accessible.

1. Start with Topical Medications

A topical formulation is both the least expensive starting point for engaging the ECS and the safest with uncommon skin side effects or the rare allergic reaction. The medications that interact with the ECS currently available for topical use include:

1. CBD
2. THC
3. BCP
4. PEA

There is good evidence that topical CBD, β-caryophyllene (BCP) and PEA are effective for joint pain, muscle pain and peripheral neuropathy pain while evidence for. the effectiveness of topical THC for pain is limited. It can be useful to first engage each of these medications independently to assess their individual usefulness then proceed to use them in various combinations to gain the most benefit.  But practically speaking it. may be preferred to take advantage of commercial products that combine some of these medications. For in-depth information regarding the use of topical medications for, including these four, see: Topical Medications for Pain.

If these product are effective, it establishes the fact that their components or their combinations work! While a topical application only reach the skin and regional tissues, these compounds can potentially provide even more benefit if taken orally where they can enter the blood stream and access the same receptors present in deeper tissues and the nervous system where the most important pain processing occurs.

2. Next, add an oral supplement with these compounds

When you identify the degree of benefit with use of the topical medications, explore oral formulation with these compounds while continuing to use the topical product as desired. Start with CBD at a dose of up to 25-50 mg/day but consider increasing the dose up to 1600mg/day,  at night or split in two daily doses 12 hours apart. This dosage range should adequate to establish if CBD offers benefit for pain or other conditions. Some people with rheumatoid arthritis or severe anxiety or insomnia may need higher doses. It should be noted that current research has yet to provide good evidence for the use of oral CBD for pain, with some studies identifying benefit but many failing to identify benefit possibly due to inadequate dosing or poor study design.

IF:

1. If the addition of the oral formulation of CBD provides no further benefit over the use of the topical CBD, discontinue the oral formulation and maintain use of the topical formulation only.

or

2. If the addition of the oral formulation of CBD is more effective than the topical alone, discontinue the topical to determine if the oral formulation by itself is better than the combination of the topical and oral formulations. If discontinuing the topical results in diminished benefit, then one nay need to use both the topical and oral formulation to achieve maximum benefit.

Exploring Formulations with CBD, BCP, PEA and THC

While there may be other products of equivalent effectiveness available, currently the best recommendation is a liquid formulations with high concentrations of CBD, BCP and PEA along with multiple other antioxidants and anti-inflammatories, a series of products by CarolinaCannabinoids. There are three separate formulations, one without any THC and two others with low and high dose THC. Because the two products with therapeutic levels of THC still contain less than 0.3% THC, they are legal in Louisiana as over-the-counter medications.

Due to both the greater expense, and the greater potential risk for side effects, start with the formulation that does not have THC in it. If your goals are met without the need for THC, continue with this product. However, if one prefers to seek greater benefits, proceed to a trial of the lower dose THC product first, and then move to the higher dose THC products as desired.

These products are water soluble, self-microemulsifying formulations that provide enhanced absorption and greater bioavailability than most other CBD products. The CBD “only” product does have trace amounts of THC, not enough to cause side effects, but enough to trigger a positive drug screen for marijuana. These products should be avoided by those with safety sensitive employment or those who are subject to drug screens at work.

3. Add Palmitoylethanolamide (PEA)

If the CarolinaCannabinoids. products are not suitable, consider a trial of palmitoylethanolamide (PEA), a natural food-based supplement that has extensive research demonstrating its effectiveness for nerve pain and inflammation, and especially neuroinflammation. In fact, the clinical evidence for PEA in human studies of pain is better than that for CBD. It has no side effects and is less expensive than CBD.

PEA has multiple mechanisms implicated in how it works but one important mechanism involves the endocannabinoid system (ECS) where PEA works synergistically with CBD and BCP. For example, BCP induces the ECS to manufacture endocannabinoids that relieve pain and PEA inhibits the enzyme that breaks down the endocannabinoids so they last longer and maintain greater pain benefit.

Oral PEA vs Topical PEA

PEA can be taken orally or applied topically. For those with peripheral neuropathy (PN), it is advised to start the PEA trial with topical PEA to areas affected by PN. Next, add oral PEA to determine if oral PEA plus topical PEA is more effective than the topical PEA alone. As above with CBD, one must determine the relative benefits of topical vs oral vs the combination of both formulations of PEA to conclude which provides the best, most cost-effective benefit.

PEA Dosing

The topical PEA should be applied 3-4x/day initially to assess benefit, then adjust the dose as needed. The usual oral dose for PEA is 600 mg twice a day. It may take 2-4 weeks for the benefits of PEA to manifest.

See: Palmitoylethanolamide (PEA)

4. Add Tetrahydrocannabinol (THC)

When trials of the above approaches still do not meet one’s desired cannabis-based therapeutic goals, then adding THC to the mix is the next step. In Louisiana, adding THC requires a prescription/”recommendation” from a physician licensed to prescribe THC-based products. Chronic pain associated with a failed response to conservative, conventional treatment is legally eligible for management with THC products, but this should be evaluated by a physician.

Currently available THC-based products have different strengths and combinations of THC, CBD and terpenes. Selecting the most appropriate THC product and dose should be based on evaluation by your physician. However, certain considerations for adding THC include:

Start low, Go slow

Because THC is responsible for most of the side effects associated with the use of marijuana-base products, the inexperienced individual should consider starting with an oral formulation. It is easier to control dosing with an oral product than one that is inhaled and therefore for the beginning user n oral product is the safest approach to avoid unnecessary side effects. Begin with low doses of an oral THC tincture, 2-5 mg at first, using one to five drops at a time. Slowly increase the dosage by adding more drops after you see how you feel. Wait 15 minutes to determine the effects and if needed, slowly increase the dosage by adding another drop and waiting an additional 15 minutes. Repeat this process until you determine how much is enough to relieve your symptoms. As one becomes familiar with the effects of THC, doses can be slowly increased based on effectiveness and tolerability, but the inexperienced user will not likely need to exceed 10 mg per dose initially. THC dosing should be guided by its purported benefits. In addition to its benefits for pain, THC also promotes relaxation, appetite, pleasure, euphoria, and it may reduce depression.

THC:CBD Ratios

The therapeutic benefits of THC and CBD may be influenced by the ratio of these two cannabinoids. For pain benefits, it is probably best to start with a balanced formulation with equal amounts of THC and CBD. For anxiety and sleep benefits, higher doses of CBD compared with THC may be advisable. It has been reported that lower CBD doses may be stimulating and energizing whereas higher CBD doses become sedating, but these effects are individually determined. Lower THC:CBD ratios are purported to have less THC-based side effects, including increased appetite, anxiety, impaired thinking and the “high.” As a general rule, the THC:CBD ratio should be started low and increased as needed based on therapeutic benefits as well as side effects: a bit of trial and error is necessary.

Choice of Form

THC comes in liquid tinctures, edible forms, and inhalable forms for smoking or vaping, and topical forms, creams and balms. Topical forms are safest because they are unlikely to have side effects. But  topicals offer no effects on anxiety, sleep, relaxation or appetite, so their clinical application is limited to localized relief of pain, inflammation, or skin conditions.

Tinctures are usually the preferred form to start medical marijuana when seeking additional benefits other than pain, especially in regards to determining an appropriate dosage. Tinctures are drops taken under the tongue that allows quicker absorption into the bloodstream. Their effects are felt within 5-15 minutes and can last for 30 minutes to 3 hours.

Edibles are the most psychoactive, intoxicating, and unpredictable method of using cannabis and may be subjectively different from inhalaed use. It is very difficult to predict how one will react to an edible and how much will be too much. Start with a very small dose of edibles and wait for a full 1 to 2 hours to determine its effects before taking more. It is very easy to over-medicate with edibles because their effects may take up to several hours to begin working. Taking more edible before the first dose begins working can lead to unwanted side effects (drowsiness, anxiety, headaches).

Choice of Formulation

THC products are available as isolates that have only THC in them, such as tinctures and edibles. Since THC is likely to work better when combined with CBD and appropriate terpene profiles based on the condition(s) treated, THC isolates may be the best choice, therapeutically and financially, as long as they are taken with appropriate CBD/terpene products. On the other hand, THC products, especially flowers, that have their own terpene profiles may have the advantage of supplementing additional terpenes for their specific therapeutic benefits, even when combined with a CBD/terpene product.

When selecting a cannabis strain, there are 3 categories of strain – Indica, Sativa, or Hybrid. Indica strains tend to be relaxing and best for evening or sleep. Sativa strains tend to be energizing and uplifting and usually best for daytime use. Hybrid strains can be indica-dominant or sativa-dominant. Indica-dominant hybrids are likely to be relaxing but not too sedating. Sativa-dominant hybrids are likely to be energizing with some relaxation. This commonly promoted description of strain properties may serve as a starting point but unfortunately it is generally over-simplified and inaccurate due to massive interbreeding of strains over recent years. Of note, none of the cannabis flowers offered by the LA-based dispensary pharmacies have significant amounts of CBD in them. See:Selecting Flower Products

5. Add Alternative Agents to Facilitate Pain Management

Finally, if the combination of THC, CBD, terpenes and PEA do not achieve ones therapeutic goals, the next step is to add other nutriceutical supplements that may work synergistically with these compounds and the endocannabinoid system. These other agents include NRF2 activators and anti-inflammatories such as curcumin, resveratrol and quercetin.