Cannabis Dosing Guide
- Successfully using cannabis as a pharmaceutical depends on controlling its psychoactive properties. Your sensitivity to THC, the high causer, is critical for finding the most effective treatment regimen. Many people enjoy the high THC gives them, and some do not.
- You do not need to get high or smoke marijuana to reap the benefits of medical cannabis.
- CBD, unlike THC, is not psychoactive. Sometimes necessary, CBD-rich formulations in high doses are well tolerated and safe.
- CBD in higher doses is not always more efficient than lower doses. It has been proven that CBD as little as 2.5mg along with a tiny amount of THC can have therapeutic effects.
- CBD-rich full-spectrum cannabis oil, containing small amounts of THC, has been shown in preclinical studies to be more effective at lower doses and has a wider array of therapeutic effects than pharmaceutical-grade, pure CBD does.
- Less is often more. Cancer patients who consumed 21mg/day of a sublingual cannabis spray with approximately equal parts of CBD to THC, called Sativex, experienced a more substantial reduction in pain than those who consumed 52mg, while patients who had taken 83mg of Sativex experienced a reduction in pain no better than those on a placebo.
- When ingesting THC-rich cannabis with little CBD it is recommended to be cautious when trying to find the right dose. Microdosing as small as 2.5mg of THC can relieve symptoms without the high feeling. If it's tolerated well, then consider increasing the amount THC slowly each day to reach a total of 15mg divided equally throughout the entire day.
- Exceeding cumulative doses, 20-30mg of THC per day, or 10+mg in a single dose may cause unwanted side effects.
- If you've never used cannabis before, it may be best for you to start with a low dose of a CBD-rich product with little THC, then slowly increase the dosage, as well as the amount of THC if necessary. Take it one step at a time. If seeking all day relief take a few small doses every 4-6 hours rather than trying to consume it all at once.
Finding the best dose of cannabis for you might require some trial and error. You may also find a greater therapeutic impact with a more balanced ratio of THC and CBD, rather than either one on its own. Modify the amount of each THC and CBD until you feel the most relief with the right combination of both compounds. Ideally, you want to stick with consistent and measurable doses of CBD with an amount of THC that you are comfortable with.
The medical benefits are fairly easy to receive from cannabis. Just one or two puffs of a resin-rich joint can do the trick for many people. Although smoking marijuana is not the only way to experience medical benefits or get high off of cannabis.
Over the past few years, the advent of non-psychotropic CBD products, potent cannabis oil concentrates, and smokeless, innovative delivery options have revolutionized therapeutic possibilities and altered the nation's conversation around cannabis.
The question is no longer if marijuana has medical value, but how do we optimize the therapeutic use of marijuana for each individual. That could provide a challenge for doctors and patients alike. As it is just now becoming a popular pharmaceutical, most medical practitioners were never taught about cannabis in medical schools, and according to a survey in 2017, very few think that they are qualified to counsel patients about the dosing as well as the different THC:CBD ratios, modes of administration, and potential side effects.
The director of Integr8 Health (treating patients in Maine and Massachusetts), Dustin Sulak, D.O., said, "Dosing cannabis is unlike any therapeutic agent to which I was exposed in my medical training." He continued to explain that it affects everyone in such a different way, some people are able to use tiny amounts of cannabis (1mg) and others consume incredibly high doses (2000mg) daily, while they both see the same benefits without any adverse effects.
Marijuana and CBD can be found in many different forms with a wide range of potencies, many times the suggested dose on the packaging should not be followed, and their production and distribution are yet to be standardized within the states.
Then, how do we proceed when cannabis dosing seems to be all over the map?
Using cannabis successfully as a medicine relies greatly on managing the psychoactive properties of THC (tetrahydrocannabinol). The cannabis high is enjoyed by many but others find it unpleasant, and how sensitive a person is to THC is the main component in implementing an effective treatment dosage.
Cannabidiol or CBD is another compound of cannabis but it does not create a psychoactive high that THC does, and in fact, depending on the ratio of each compound present in the product, it can actually neutralize or lessen the THC high. Now patients using cannabis have the option for relief without the high.
Generally, there are three main types of resin-rich cannabis or cannabis products:
- Type 1: THC Dominant - High THC to low CBD ratio
Ever-present psychoactive marijuana that millions like to smoke
- Type 2: THC and CBD - Similar mixed THC and CBD ratio
Psychoactive but not as much as THC dominant types
- Type 3: CBD Dominant - High CBD to low THC ratio
Non-euphoric marijuana or then considered hemp
A fourth type can also be cultivated but they are rare forms of cannabis that prominently contain a less known cannabinoid that is typically hard to produce a large amount of such as CBG or THCV. As far as what's available for patients currently, the THC:CBD ratio is superior and needs to be considered while creating a dosage strategy.
What’s the proper dose for the three types of cannabis?
Microdosing for beginners
A typical misconception is that patients can not get symptom relief without also getting high from cannabis therapy.
Doctors find that ultra-low doses of cannabis can be extremely effective, often times more than a high dose. These lower doses are not enough to produce impairment or euphoria but still produce the needed therapeutic effects.
Preclinical science believes in the idea that small amounts of THC can provide health benefits. In 2005 a report in Nature detailed an animal model with hardening of the arteries that was given a low dose of THC, only 1mg a day, orally, and found the disease progression was significantly inhibited. They also noted that the 1mg dose is lower than that, which is normally associated with the psychotropic effects of THC.
The prohibition of cannabis federally as well as research restrictions is causing a lack of clinical data to determine and support if low doses of THC therapy can actually protect against atherosclerosis in humans. Dispite this, micro-dosing - which involves consuming sub-psychoactive or marginally psychoactive doses of cannabis - is quickly increasing in popularity among people who want the medical bennefits but not the high of cannabis.
Even though it's banned federally, cannabis medicine in measurable doses are currently available in many different forms including concentrated oil extracts, edibles, gel caps, infused sublingual sprays, topical salves, tinctures, and other products.
“Start low, go slow”
The adage “start low and go slow” is apropos for cannabis therapy, in general, and THC titration, in particular, as discussed by Caroline MacCallum and Ethan Russo in a January 2018 article in the European Journal of Internal Medicine. The authors, who are both physicians, provide sensible guidelines for health professionals and patients regarding the judicious administration of (Type 1) THC-dominant medicinal preparations.
If a new patient is going to smoke or vape THC-rich cannabis, Russo and MacCallum suggest they start with a single inhalation and wait 15 minutes before inhaling again. The effects of inhaled cannabis usually can be felt within a few minutes, thereby providing quick relief of acute distress. If need be, one can inhale an additional puff every 15 to 30 minutes “until desired symptom control is achieved.”
As for oral administration, one should keep in mind that it can take 60 to 90 minutes before the effects of a single dose are felt.
MacCallum and Russo suggest a carefully titrated regimen for consumption of ingestible THC-rich cannabis products. They recommend that patients with little or no experience using cannabis should start by ingesting the equivalent of 1.25 to 2.5 mg of THC shortly before bedtime for two days. If there are no unwanted side effects, increase the bedtime dose of THC by another 1.25 to 2.5 mg for the next two days. Continue to increase the dose of THC by an additional 1.25 to 2.5 mg every other day until the desired effects are achieved.
If there are adverse side effects, reduce the dose of THC to the prior amount that was well tolerated.
Type 1 – Titrating THC
For adequate symptom relief, some patients may need to ingest a cannabis preparation two or three times during daylight hours in addition to their night-time regimen. Again, cautious titration is urged: On days 1 and 2, start with one dose of the equivalent of 2.5 mg THC; on days 3 and 4, increase to 2.5 mg THC twice a day; and, if well tolerated, up the dose incrementally to a total of 15 mg THC (divided equally throughout the day).
“Doses exceeding 20-30 mg/day [of THC] may increase adverse events or induce tolerance without improving efficacy,” the authors warn.
Adverse events mainly pertain to THC and are dose-dependent. Very high doses are more likely to cause unwanted side effects.
For most medications, a higher dose will pack a stronger therapeutic punch. With cannabis, however, it’s not so simple. THC and other cannabis components have biphasic properties, meaning that low and high doses generate opposite effects. Small doses of cannabis tend to stimulate; large doses sedate.
In practical terms, this means that starting low and gradually upping the dose of cannabis will produce stronger effects at first. But, after a certain point, which differs for each person, “dosage increases can result in weaker therapeutic effects,” according to Dr. Sulak, “and an increase in side effects.”
Sulak observes that “symptoms of cannabis overdose closely mirror the symptoms one would expect cannabis to relieve at appropriate doses: nausea, vomiting, diarrhea, sweating, spasms, tremors, anxiety, panic attacks, paranoia, dis-coordination, and disturbed sleep. Extreme overdoses can lead to hallucinations and even acute psychosis.”
Type 2 - THC and CBD: Power couple
Although many patients do well at the lowest effective dose, some benefit more from a high dose cannabis oil regimen, preferably one that includes a substantial amount of CBD as well as THC. By lowering the ceiling on THC’s psychoactivity, CBD makes high potency cannabis oil treatment easier to manage. If high doses are necessary, steady titration over several weeks will help build a tolerance to THC’s tricky psychoactive effects.
CBD and THC are the power couple of cannabis therapeutics. Both compounds have remarkable medicinal attributes, and they work better in combination than as isolates. CBD can synergistically enhance THC’s anti-inflammatory and painkilling properties, for example, while reducing unwanted side effects.
A clinical study published in the Journal of Pain examined the efficacy of different dosage levels of Sativex, a cannabis-derived sublingual spray with 1:1 CBD:THC ratio, which is an approved medication in two dozen countries (but not in the United States). Of 263 cancer patients who were not finding pain relief with opiates, the group that received 21 mg of Sativex each day experienced significant improvements in pain levels, more so than the group that received 52 mg Sativex daily. And those given even higher doses (83 mg daily) reduced their pain no better than a placebo, but they experienced more adverse effects.
Cannabis therapeutics is personalized medicine. There is no single CBD:THC ratio or dosage that’s optimal for everyone. As little as 2.5 mg of CBD combined with a small amount of THC can have a therapeutic effect. If necessary, much higher doses of good quality CBD-rich formulations are safe and well tolerated.
For cannabis-naïve patients, it may be best to start with low doses of a CBD-rich remedy (with little THC) and increase the dosage (and, if necessary, the amount of THC) step-by-step. Take a few small doses over the course of the day, rather than one big dose.
But a low-THC product is not always the best treatment option. A more balanced combination of CBD and THC could have a greater impact than CBD or THC alone.
In essence, the goal is to administer consistent, measurable doses of a CBD-rich remedy with as much THC as a person is comfortable with. Experiment, observe the effects and adjust the amount of CBD and THC until one finds the sweet spot with the right combination of both compounds.
Type 3 – Full-spectrum CBD-rich extracts
Microdosing cannabis is a feasible option for those who prefer not to leap over the psychoactive threshold. High dose CBD therapy is another way of healing without the high.
As a general rule, Type 3 CBD-dominant cannabis (with little THC) won’t make a person feel stoned. Nor will a pure CBD isolate (with no THC). But CBD isolates lack critical aromatic terpenes and other cannabinoids, which interact synergistically to enhance CBD’s therapeutic benefits. Single molecule cannabinoids are simply not as versatile or as efficacious as whole plant formulations.
Preclinical research indicates that full spectrum CBD-rich cannabis oil is effective at much lower doses and has a wider therapeutic window than a CBD isolate. “The therapeutic synergy observed with plant extracts results in the requirement for a lower amount of active components, with consequent reduced adverse side effects,” a 2015 Israeli study concluded.
In animal studies, CBD isolates require very high – and precise – doses to be effective. Problematic drug interactions are also more likely with a high-dose CBD isolate than with whole plant cannabis.
Hemp-derived CBD isolates and distillates are already available via numerous internet storefronts. Drug companies are also eyeing single molecule CBD as a treatment for intractable epilepsy, psychosis, and other diseases.
In a 2012 clinical trial involving 39 schizophrenics at a German hospital, 800 mg of pure pharmaceutical-grade CBD proved to be as effective as standard pharmaceutical treatments without causing the harsh side effects typically associated with antipsychotic drugs. But a follow-up study at Yale University found little cognitive improvement in schizophrenics who were given a CBD isolate.
Bereft of the THC stigma (and its therapeutic moxy), single-molecule CBD will soon become a FDA-approved pharmaceutical for pediatric seizure disorders. This is good news for families with epileptic children that have health insurance. Anyone without health insurance won’t be able to afford Epidiolex, a nearly pure CBD remedy developed by GW Pharmaceuticals as an anti-seizure medication.
Consider the dosage range utilized in clinical trials of Epidiolex. Children with catastrophic seizure disorders were given up to 50 mg of Epidiolex per kg of body weight. Such high doses caused interactions with other anticonvulsant medications, requiring adjustments of the latter to avoid a toxic overdose.
By comparison, Dr. Bonni Goldstein, author of Cannabis Revealed, typically starts with a much lower dose of full spectrum CBD-rich oil (1 mg CBD/kg of body weight) for epileptic children – with the understanding that the dose may have to be lowered or raised depending on the initial response. If necessary, Goldstein will increase the dose of CBD by increments of 0.5 mg/kg until a threshold of 5 mg/kg of body weight is reached. And that amount also may need to be adjusted.
Kids and adults metabolize drugs differently. It may seem counterintuitive, but young children can tolerate high doses of cannabis oil concentrates, including THC-rich formulations, which might be daunting for an adult. Thus, it’s not a good idea to calculate dosage for an adult based on what works for a child.
If 1 mg/kg of CBD is an appropriate starting dose for a child, and an adult weighs 15 times more than the child, one should not assume that the correct CBD starting dose for the grown-up is 15mg/kg of body weight. That could be way too high a dose. While CBD has no known adverse effects at any dose, an excessive amount of CBD may be less effective therapeutically than a moderate dose.
Similarly, it’s not a good idea to devise a dosage regimen based on data from preclinical animal studies, which usually involve high doses of single-molecule cannabinoids. Human metabolism differs from mice and rats, and data from animal models don’t always translate to human experience.
For people as well as pets, cannabis dosing must be individually determined. Several factors come into play, including one’s overall health and endocannabinoid tone, which are influenced by diet, exercise, sleep patterns, day-to-day stress, and genetics. Cannabis is best used as part of a healthy lifestyle.
Here are some dosing variables to consider:
- Cannabis experience. Is the patient cannabis-naïve? Or a stoner who already uses cannabis every day but isn’t getting the best results? A veteran user may need a higher dose than a new user. Or a chronic user might need a break from getting high to reboot his or her sensitivity to cannabis (see Dr. Dustin Sulak’s cannabis “sensitization protocol” on Healer.com).
- Time of day. Optimizing one’s therapeutic use of cannabis may entail using products with different CBD:THC ratios at different times of the day – more CBD for daylight hours, more THC at night.
- Preventive dosing. Prolonged low dose therapy may be advantageous for managing chronic symptoms or to prevent disease recurrence. Preclinical studies indicate that cannabinoids have neuroprotective and cardioprotective properties that could limit the damage of a traumatic brain injury or a heart attack.
- Cannabinoid acids. Raw, unheated cannabis contains CBD and THC in their “acid” form, CBDA and THCA, which are not intoxicating. Consumed orally over several months, cannabinoid acids can be effective in very small amounts, but precise dosing is difficult when juicing raw cannabis. Other delivery systems are becoming available for CBDA-rich and THCA-rich products.
Cannabis is a safe and forgiving medicine. Figuring out how to make the most of its health-enhancing properties may involve some trial and error. No worries! At least cannabis isn’t harmful like so many FDA-approved pharmaceuticals.
So if you’re new to cannabis medicine or if you’re seeking to improve your therapeutic routine, remember this advice from Dr. Sulak: “Start low, go slow, and don’t be afraid to go all the way!”
Project CBD director Martin A. Lee
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