Accurate Education – Marijuana (Cannabis): Getting Started

Marijuana (Cannabis): Getting Started

 

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.

 

For those patients who are interested in pursuing a trial of therapy with cannabis-based products, it is important they first read the following pages on this website:

 

Medical Marijuana Legislative Update

Medical Marijuana Use Overview

Cannabidiol (CBD) – Introduction

Cannabidiol (CBD) – Clinical Use

Cannabidiol (CBD) – Drug Actions & Interactions

 

It is also highly recommended to read:

Palmitoylethanolamide (PEA)

NRF2 Activators

  

See also:

Marijuana – Cannabinoids and Opioids

 

Cannabis-Based Medications:

Over-the-Counter Cannabinoid Medications:

Cannabidiol (CBD) – Introduction

Cannabidiol (CBD) – Clinical Use

Cannabidiol (CBD) – Drug Actions & Interactions

 

Prescription Cannabis-Based Medications:

FDA-Approved Prescription Cannabis-Based Medications

Louisiana Prescription Cannabis-Based Products – “Medical Marijuana”

 

Clinical Applications of Cannabis:

Cannabis – Anxiety (coming soon)

Cannabis – Fibromyalgia

Cannabis – Headaches (coming soon)

Cannabis – Inflammatory Bowel Disease (coming soon)

Cannabis – Neuroinflammation (coming soon)

Cannabis – Chronic Pain Overview

Cannabis – Sleep (coming soon)

 

The Medical Science of Cannabis:

The Endocannabinoid System

Marijuana – Botanical

Marijuana – Pharmacokinetics

Marijuana – Inhaled (Smoked and Vaporized)

Marijuana – Cannabinoids and Opioids

 

Cannabinoids and Terpenes:

Cannabinoids & Terpenes – An Overview (coming soon)

Cannabinoids:

Marijuana – Cannabidiol (CBD) – Introduction

 

 Terpenes:

Terpenes – An Overview (coming soon)

   

See also:

Marijuana – Discontinuing Use

Marijuana Addiction – Cannabis Use Disorder (CUD)

 

Key to Links:

Grey text – handout

Red text – another page on this website

Blue text – Journal publication

cannabis-caduceus 

 

Cannabidiol Oil

Getting Started with Marijuana (Cannabis)-based Medications for Pain

– A Brief Overview

The recent introduction of marijuana-based products for medical use has coincided with two important developments in the understanding of chronic pain. First is 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. Second, the recent discovery of the Endocannabinoid System (ECS) in mammals that is responsible for the therapeutic effects of marijuana including its role in chronic pain.

 

The insights gained in these two arenas are the basis of the following recommendations for getting started with these new “tools in the toolbox” of chronic pain management.

 

Available research indicates that the pain relieving benefits of marijuana (cannabis) are most effective for nerve (neuropathic) pain – pain usually perceived as burning or electric, sometimes sharp or stabbing, which may start in one location and shoot to another (See: Neuropathic Pain). Other types of pain such as dull, aching or throbbing pains may not be as responsive.

 

Understand also, however, that the distinction between neuropathic pain and other types of pain becomes very blurred when it comes to 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 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 to analgesic benefits of opioids over time. Research suggests cannabis-based agents as well as PEA may reduce opioid tolerance and improve the analgesic benefits of opioids by reducing neuroinflammation and via 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.

 

Cannabis has also been found to sometimes be effective for anxiety, sleep and possibly 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.

 

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 Palmitoylethanolamide (PEA)

PEA is a natural food-based supplement that has extensive research demonstrating its effectiveness for nerve pain and inflammation, 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 cannabidiol (CBD). PEA has multiple mechanisms implicated in how it works but one important mechanism involves the endocannabinoid system and research suggests that PEA works synergistically with cannabinoids such as CBD and THC.


The usual dose for PEA is 600 mg twice a day. It may take 2-4 weeks for the benefits of PEA to manifest. If the initial trial of PEA is ineffective on its own, add CBD.

See: Palmitoylethanolamide (PEA)

 

(2) Add Cannabidiol (CBD) to PEA

Working in conjunction with PEA, CBD offers additional benefit for relieving pain and potentially also reducing anxiety, aiding sleep and possibly reducing muscle spasm. A review of the different CBD formulations is listed below.

Cannabidiol (CBD) – Introduction

Cannabidiol (CBD) – Clinical Use

 

It is recommended that one understand the differences in CBD formulations, both legal and medical, before selecting a product. Also, be aware that CBD products come in different forms: liquid tinctures, capsule, edibles and topical creams. Preparations designed to be smoked or “vaped” are not legal and are not recommended due to their very rapid onset of action and higher incidence of side effects as well as their potential toxicity to lung tissues.

 

Liquid tinctures

Liquid tinctures have the advantage of a more rapid onset of action but the therapeutic effects don’t last as long as capsules taken orally. The other problem with tinctures is their difficulty in determining actual dosing because they come in a wide range of concentrations which are delivered by droppers. It often requires complicated arithmetic to determine the actual dosage taken.

 

Capsules

Capsules are recommended as the product of choice, at least when getting started, because they have the advantages of distinct dosing that is easy to monitor and their therapeutic effects last longer than other forms.

 

Edibles

Finally, there are edible products like “gummies.” Edibles are not recommended due to their reinforcement for increasing dosing based on their palatability. Furthermore, edibles are more likely to be accidentally ingested by children, pets or others who may mistake them for food.

 

Certificates of Analysis

It is strongly advised that one obtain the certificate of analysis described below before purchasing a CBD product. Most importantly, it is very strongly advised to bring both the CBD product and the certificate of analysis to the physician for review. Pay particular attention to the dosing of the CBD product as the different formulations can be confusing.

 

Dosing of CBD

Dosing of CBD is not well established and will vary depending on the formulation and the individual. Most CBD products should be initiated at a dose of  3-5 mg, 2-3 times per day. If this dose is ineffective, the dose should be gradually increased to achieve benefit. Doses up to a range of 500-1000 mg/day have been studied for different conditions and determined to be safe. If the addition of CBD product(s) is ineffective with PEA, add THC.

See Cannabidiol (CBD) – Clinical Use

 

(3) Add Delta-9 Tetrahydrocannabinol (THC) to PEA and CBD

Adding THC requires a prescription/”recommendation” from a physician licensed in Louisiana to prescribe cannabis-based products. Chronic pain associated with a failed response to conservative, conventional treatment is usually legally eligible for management with THC products but should be evaluated by a physician. THC products are expected to become available by January or February, 2019.

 

At this time the specific THC products that will become available have not been identified. It is expected that the products will have different strengths and combination ratios of THC and CBD, with some products high THC/low CBD, some low THC/high CBD and others possibly as isolates of THC and CBD. Both the amounts/doses and ratios of the components will need to be determined by the physicin bssed on patient complaints and a bit of trial and error to elicit a response. As a general rule, the THC:CBD ratio will be started low and increased as needed based on therapeutic benefis as well as side effects.

 

If the addition of THC/CBD products are ineffective it may be fruitful to look at what options are available for the addition of other cannabinoids and terpenes within other cannabis-based products which are not yet available. Hopefully more options will be available soon.

 

Finally, if the addition of THC/CBD and other cannabinoids and terpenes are ineffective, the next step would be to add other nutriceutical supplements believed effective for pain and other sympoms. These other agents may include NRF2 activators and anti-inflammatories such as curcumin (Meriva), Resveratrol and quercetin. There is reason to believe these agents may also work synergistically with cannabis-based products to reduce pain.

 

(4) Add Alternative Agents to Facilitate Pain Management

Depending on the nature of the pain and condition involved, additional supplements may be suggested to help with inadequately c0ntrolled pain as synergistic agents to work with cannabis-basesd products.

 

See:

NRF2 activators (Meriva, Resveratrol,  Quercetin)

SynaptGenX

 

Getting Started with Cannabidiol (CBD)

Legal, Over-the-Counter (OTC) CBD

CBD Isolate Products

CBD isolate products are legal without a prescription in Louisiana, and are the product of choice for those who get drug tested. A CBD “Isolate” is 99+% pure CBD, with no other cannabinoids such as THC and no terpenes. (See Cannabidiol (CBD) for more details on different CBD formulations and dosing.

 

When shopping for a CBD isolate, it is important to verify the purity.The quality of over-the-counter CBD available in the local market and over the internet varies and may not be as advertised and many are not THC-free. Before purchasing a CBD product review the “product analysis” sheet provided by the manufacture and available to the consumer. The product analysis sheet is a third party assessment of the constituents found in the CBD product including all cannabis-based agents as well as contaminants. If your sales person cannot provide a product analysis sheet, do not purchase the product. (See: Sample CBD Isolate product analysis sheet).
 
 
Look for products with labels clearly showing the quantity and concentration, a manufacturing date, and a batch number (for quality control). Choose products without corn syrup, trans-fats, GMOs, artificial additives, thinning agents or preservatives. Look to see if they have been lab tested and verified as being free of mold, bacteria, pesticides, solvent residues, and other contaminants. Avoid CBD products extracted with toxic solvents like BHO, propane, hexane or other hydrocarbons. Instead, select products utilizing safer extraction methods such as supercritical CO2 or food-grade ethanol. Beware of disreputable sources and avoid purchasing from gas stations or questionable web sites.
 

CBD Broad Spectrum and Full Spectrum Products

Due to the absence of other pharmacologically active cannabis constituents, CBD isolates may be less effective than the CBD broad or full spectrum products that do contain these other constituents, the cannabinoids and terpenes. Broad spectrum products contain other constituents but have non-detectable, 0% THC whereas full spectrum products contain other constituents but <0.3% THC. CBD products listed as being derived from “whole plant” or “aerial parts” are likely to be broad or full spectrum.

 

While it appears to be technically illegal, it seems that broad and full spectrum CBD products are allowed to be sold in LA as long as the THC content is less than 0.3%. These products would not be expected to produce a high or euphoria but full spectrum CBD products might possibly trigger a positive urine drug screen for THC.

 

For the same reasons as noted above, before purchasing a CBD product review the “product analysis” sheet. If your sales person cannot provide a product analysis sheet, do not purchase the product. For broad and full spectrum CBD products, it is especially important to obtain the product analysis sheet and bring it to the clinic with the CBD product for assessment by the physician. As more knowledge becomes available regarding the clinical effects of other cannabinoids and terpenes, assessment of their content may be helpful in selecting the most effective CBD product based on the patient’s clinical needs.

 

Dosing of CBD

CBD can be effective at a really wide range of dosages and there hasn’t been a lot of studies on human subjects. It has been noted that very low doses can have a very profound impact, from as little as 2.5 mg of CBD (which isn’t a lot) up to hundreds of milligrams per dose. 

 

A very high dose may also not provide additional benefit over a low dose, so it’s best to start with a low dose: 2.5-5 mg of CBD initially (maybe 10mg at the most), depending on the product and method of use. A typical starting CBD dose for most people would be a total of 10-15 mg of CBD a day, divided into 3 daily doses. If the desired effect is not achieved at a low dose, then gradually higher doses can be introduced until the therapeutic goal is achieved or side effects deter further increased dosing.

 

The use of tinctures sublingually would be be expected to provide a more rapid onset of effect but may not last as long. Orally administered CBD oil can last for four hours or more, but the onset of effects is much slower (30-90 minutes). Tincture dosing is generally performed with a 1 ml dropper which provides about 20 drops/ml.

 

 

  

Resources:

National Academy of Sciences

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

 

These lay-person websites appear to be good resources for exploring medical marijuana:

  1. www.GreenCamp.com
  2. www.Healer.com
  3. www.MedicalJane.com
  4. www.ProjectCBD.org

 

 

References:

Epidiolex (cannabidiol)

  1. FDA approves CBD drug – Epidiolex – The Washington Post

Marinol (dronabinol)

  1. Marinol – dronabinol

 

 

Medical Marijuana – Federal Law

  1. The legal status of cannabis (marijuana) and cannabidiol (CBD) under U.S. law – 2017

Medical Marijuana – Louisiana Law

  1. Louisiana-2016-SB180-Chaptered
  2. HOUSE BILL NO. 225 – 2017 Regular Session
  3. Louisiana medical marijuana expansion bill signed into law – May 20, 2016
  4. Now in Effect, Louisiana Medical Marijuana Law Shields Patients and Caregivers from Prosecution – Aug 5, 2016
  5. Louisiana-2016-SB180-Chaptered

Cannabidiol (CBD)- Overviews

  1. CANNABIDIOL (CBD) Pre-Review Report WHO 2017
  2. Cannabidiol – State of the art and new challenges for therapeutic applications. – 2017 PubMed – NCBI

 

CBD – Anxiety

  1. Overlapping Mechanisms of Stress-Induced Relapse to Opioid Use Disorder and Chronic Pain – Clinical Implications – 2016
  2. Cannabidiol Modulates Fear Memory Formation Through Interactions with Serotonergic Transmission in the Mesolimbic System – 2016
  3. Cannabidiol regulation of emotion and emotional memory processing: relevance for treating anxiety-related and substance abuse disorders. – PubMed – NCBI
  4. Review of the neurological benefits of phytocannabinoids – 2018
  5. Plastic and Neuroprotective Mechanisms Involved in the Therapeutic Effects of Cannabidiol in Psychiatric Disorders – 2017
  6. Neural basis of anxiolytic effects of cannabidiol (CBD) in generalized social anxiety disorder: a preliminary report. – PubMed – NCBI
  7. Evidences for the Anti-panic Actions of Cannabidiol – 2017
  8. Cannabidiol, a Cannabis sativa constituent, as an anxiolytic drug – 2012
  9. Cannabidiol Reduces the Anxiety Induced by Simulated Public Speaking in Treatment-Naïve Social Phobia Patients – 2011

 

CBD – Interaction with THC

  1. Cannabidiol: a promising drug for neurodegenerative disorders? – PubMed – NCBI
  2. Oral Cannabidiol does not Alter the Subjective, Reinforcing or Cardiovascular Effects of Smoked Cannabis – 2015
  3. Taming THC – potential cannabis synergy and phytocannabinoid-terpenoid entourage effects – 2011
  4. A tale of two cannabinoids: the therapeutic rationale for combining tetrahydrocannabinol and cannabidiol. – PubMed – NCBI

 

 

CBD – Metabolites

  1. Human Metabolites of Cannabidiol – A Review on Their Formation, Biological Activity, and Relevance in Therapy – 2016

 

CBD – Drug-Metabolic Interactions

  1. Cannabidiol, a Major Phytocannabinoid, As a Potent Atypical Inhibitor for CYP2D6 – 2011
  2. The Effect of CYP2D6 Drug-Drug Interactions on Hydrocodone Effectiveness – 2014 
  3. Characterization of P-glycoprotein Inhibition by Major Cannabinoids from Marijuana – 2006

Medical Marijuana – Prescribing Guidelines

  1. Simplified guideline for prescribing medical cannabinoids in primary care – Canadian Family Physician – 2018
  2. Physician Recommendation of Medical Cannabis Guidelines Calif Medical Assoc – 2011
  3. Prescribing smoked cannabis for chronic noncancer pain. Preliminary recommendationsCanadian Family Physician – 2014

 

Medical Marijuana – Opioids

  1. Use-of-Prescription-Pain-Medications-Among-Medical-Cannabis-Patients
  2. It is premature to expand access to medicinal cannabis in hopes of solving the US opioid crisis – 2018
  3. Patterns of medicinal cannabis use, strain analysis, and substitution effect among patients with migraine, headache, arthritis, and chronic pain in a medicinal cannabis cohort – 2018
  4. Patterns and correlates of medical cannabis use for pain among patients prescribed long-term opioid therapy. – PubMed – NCBI
  5. Associations between medical cannabis and prescription opioid use in chronic pain patients – A preliminary cohort study – 2017
  6. The prevalence and significance of cannabis use in patients prescribed chronic opioid therapy: a review of the extant literature. – PubMed – NCBI
  7. The use of cannabis in response to the opioid crisis: A review of the literature. – PubMed – NCBI
  8. Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999–2010 – 2014
  9. Rationale for cannabis-based interventions in the opioid overdose crisis – 2017
  10. Cannabis and the Opioid Crisis – 2018
  11. Impact of co-administration of oxycodone and smoked cannabis on analgesia and abuse liability. – PubMed – NCBI
  12. Cannabinoid–Opioid Interaction in Chronic Pain
  13. Synergistic interactions between cannabinoid and opioid analgesics. – PubMed – NCBI
  14. FDA approves CBD drug – Epidiolex – The Washington Post

Medical Marijuana –Misc

  1. A tale of two cannabinoids: the therapeutic rationale for combining tetrahydrocannabinol and cannabidiol. – PubMed – NCBI
  2. Cannabis and cannabis extracts – greater than the sum of their parts? – 2001
  3. Medical cannabis and mental health: A guided systematic review. 2016 – PubMed – NCBI
  4. Epidemiological characteristics, safety and efficacy of medical cannabis in the elderly. – PubMed – NCBI
  5. Cannabis-conclusions – 2017 National Academy of Sciences
  6. Cannabis-chapter-highlights – 2017 National Academy of Sciences
  7. Cannabis-report-highlights – 2017 National Academy of Sciences
  8. Clinical Endocannabinoid Deficiency (CECD): Can this Concept Explain Therapeutic Bene ts of Cannabis in Migraine, Fibromyalgia, Irritable Bowel Syndrome and other Treatment-Resistant Conditions?-2004
  9. Marijuana use and the risk of lung and upper aerodigestive tract cancers: results of a population-based case-control study. – PubMed – NCBI
  10. Cannabis use and cognitive function: 8-year trajectory in a young adult cohort. – PubMed – NCBI
  11. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. – PubMed – NCBI
  12. Cannabinoids and Cytochrome P450 Interactions. – PubMed – NCBI Pharmacogenetics of Cannabinoids – 2018
  13. Systematic review of systematic reviews for medical cannabinoids – 2018
  14. Adverse effects of medical cannabinoids – a systematic review – 2008
  15. Cannabimimetic effects modulated by cholinergic compounds. – PubMed – NCBI
  16. Antagonism of marihuana effects by indomethacin in humans. – PubMed – NCBI
  17. Pharmacokinetics and pharmacodynamics of cannabinoids. – PubMed – NCBI
  18. Clinical Pharmacodynamics of Cannabinoids – 2004
  19. Affinity and Efficacy Studies of Tetrahydrocannabinolic Acid A at Cannabinoid Receptor Types One and Two. – 2017
  20. Quality Control of Traditional Cannabis Tinctures – Pattern, Markers, and Stability – 2016
  21. Exogenous cannabinoids as substrates, inhibitors, and inducers of human drug metabolizing enzymes: a systematic review. – PubMed – NCBI
  22. Pharmacology of Cannabinoids
  23. Current-status-and-future-of-cannabis-research-Clin-Researcher-2015
  24. Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems – A Clinical Review – 2015

 

Medical Marijuana – Product Evaluation

  1. The Cannabinoid Content of Legal Cannabis in Washington State Varies Systematically Across Testing Facilities and Popular Consumer Products – 2018
  2. Quality Control of Traditional Cannabis Tinctures – Pattern, Markers, and Stability – 2016

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.

 

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