I was recently discussing with friends what could be done with a hammer and I received the following answers: “build a house, hang a picture, break a wall, pry something, break a window, fix something, build a table, hit your finger, murder someone, break a piggy bank”, and “nail on a roof.” The answers received represented an important aspect of all tools which is that they can be used for constructive or destructive purposes.
In psychiatry, the medications that we prescribe and recommend are complex tools and medical cannabis is no different in this respect. Cannabis has been used for thousands of years to treat various ailments effectively, but, more recently, it has been the cause of much debate and controversy. The science continues to improve and evolve on the use of medical cannabis and like all tools, it is generally considered useful.
Cannabis creates biological and psychological effects in the human body because we have an internal signaling system called the endocannabinoid system that uses similar chemicals made by the body for immune response, inflammation reduction, pain mediation, as well as appetite, mood, and sleep functions.
For cannabis products to work, the endocannabinoid system must be primed to respond. This can be done with inexpensive CBD products by taking 5-10 mg for 2-5 days prior to using a balanced cannabis product from a medical cannabis pharmacy (often called a dispensary outside of Utah). Cannabis should be titrated with a 1:1-1:5 THC: CBD content product. Treatment naïve patients should start with 1-2 mg of THC on day one. The dose can be increased by 1-2 mg of THC daily until the target symptoms are relieved. If you begin feeling tired, dizzy, or anxious then the dose is too high and should be reduced by 1-2 mg of THC or to the last tolerated dose on the next dosing day.
It is advisable to have a CBD-only product on hand as well to moderate the effects of the THC, should side effects occur. A dose of 5 mg of CBD can be taken for each 1 mg of THC that needs to be moderated. CBD is unlikely to fully reverse all side effects of THC but can moderate them noticeably.
The route of administration will influence the time to onset and the duration of action.
Inhaled products begin working the most rapidly of all routes but will also wear off the most rapidly with effects starting in 1-10 minutes and will continue to work for 1-3 hours. (Often best suited for a rescue treatment when a rapid onset is a priority. Example: Sudden onset acute pain, nausea, or anxiety)
Sublingual products can start working in 15-45 mins and work for 3-10 hours. They are intermediate between inhaled and oral products for both onset and duration of action. (Often the easiest to titrate for beginners.)
Oral products that are ingested usually take 30 to 120 minutes to start working (can take longer) and can last for 8-16 hours. Oral products can feel more intense mg for mg compared to other routes of administration and can take more diligence/patience in titration. Absorption is variable and is increased with fatty foods. (Best suited for treatments where a longer duration of action is the priority. Example: chronic pain or chronic anxiety from PTSD)
Qualifying conditions under the Utah Medical Cannabis Act are listed below:
• HIV or acquired immune deficiency syndrome
• Alzheimer’s disease
• amyotrophic lateral sclerosis
• cancer
• cachexia
• persistent nausea that is not significantly responsive to traditional treatment, except for
nausea related to:
o pregnancy
o cannabis-induced cyclical vomiting syndrome
o cannabinoid hyperemesis syndrome
• Crohn’s disease or ulcerative colitis
• epilepsy or debilitating seizures
• multiple sclerosis or persistent and debilitating muscle spasms
• post-traumatic stress disorder (PTSD) that is being treated and monitored by a licensed
health therapist (defined here), and that:
o has been diagnosed by a healthcare provider by the Veterans Administration
and documented in the patient’s record; or
o has been diagnosed or confirmed by evaluation from a psychiatrist, doctorate
psychologist, a doctorate licensed clinical social worker, or a psychiatric APRN
• a terminal illness when the patient’s life expectancy is less than six months
• a condition resulting in the individual receiving hospice care
• a rare condition or disease that affects less than 200,000 individuals in the U.S., as
defined in federal law, and that is not adequately managed despite treatment attempts
using conventional medications (other than opioids or opiates) or physical interventions
• pain lasting longer than two weeks that is not adequately managed, in the qualified
medical provider’s opinion, despite treatment attempts using conventional medications
other than opioids or opiates or physical interventions
• a condition that the compassionate use board approves (once established) on a case-by-case basis
When it comes to cannabis, more is not always better. Effective treatment generally includes a balanced product that has both THC and CBD at moderate doses and is titrated for efficacy. The lower the dose necessary to achieve relief, the less expensive your treatment with medical cannabis will be. Balanced cannabis products with higher CBD content and lower total doses of THC have been shown to be less likely to cause addiction, misuse, or cravings. Smoking/burning of cannabis destroys 75% of active cannabinoids including THC. Smoking is not advised for efficient delivery of cannabinoids or lung health and remains Illegal in Utah. Vaporizers that heat the raw flower free more cannabinoids for use, are safer, and are readily available at the pharmacy.
It is important to remember that a tool in the hands of someone without understanding is likely to be used poorly and without grace, but with the correct training, one can learn to use any tool skillfully and constructively.
Dr. Landon Moyers, DNP, APRN, PMHNP-BC
