Prescribing Medical Cannabis to Pain Patients
A Suggested Guide on the Application and Dosing of Medical Marijuana
A total of 29 states now have existing medical cannabis laws, yet the number of prescriptions written for this drug have not increased to the extent that many originally expected. The continued Schedule I assignment of marijuana and fear of being reprimanded by the state medical board may be at least partially responsible for the apprehension of physicians, but other factors could also be at play.
For example, some doctors may not yet understand the full benefits of medical cannabis. However, it is far more likely that some simply have concerns over the safety of their patients. This concern may be exacerbated by the knowledge that many dispensaries lack sufficient training on the acceptable uses, dosage, and application of medical cannabis.
That is the purpose of this article – to provide a comprehensive guide that doctors can use when prescribing cannabis to their patients. The hope is that, in doing so, at least one concern will be resolved. At the very least, it may help patients seek and obtain the medicine they need with less confusion and fewer complications.
Studies have shown cannabis to be an effective form of treatment for a wide range of conditions. In fact, the National Cancer Institute indicates that cannabis may even inhibit the growth of certain cancers. Cannabis can also increase the efficacy of opioids by as much as 30 percent, and it often extends the duration over which opioids work. When this, along with the lower risk of addiction, shorter span and severity of withdrawals, and lack of marijuana overdose deaths are considered, cannabis certainly seems like a wise choice for patients suffering from severe or intractable pain.
THC, CBD, or Both?
Studies have examined a variety of cannabinoids, both independently and together. They have been found to work with the body’s endocannabinoid system to help manage pain. Cannabis has also been shown to work effectively for spastic disorders, metabolic disorders, and anti-inflammatory conditions. Further, it can reduce or eliminate the side effects that are commonly experienced by cancer patients undergoing chemotherapy or radiation. However, some strains and types may be more effective at treating some conditions than others.
Cannabis that contains THC, or delta-9-tetrahydrocannabinol, has been shown to work effectively at treating nausea and vomiting issues, particularly among chemotherapy patients. Animal studies suggest this may be due to the way that THC and other cannabinoids act on the body’s endocannabinoid system. It should be noted that, at least in this application (treatment for nausea and vomiting), oral applications of THC may be preferred.
THC has also been found to work as a highly effective pain reliever – equal to that of codeine – and it can reduce the frequency, dosage, and desire for opioid painkillers. This cannabinoid can also promote hunger in conditions that result in a poor appetite. If combined with CBD, it may also enhance the efficacy of temozolomide when treating recurrent glioblastoma multiforme.
CBD, or cannabidiol, is a non-psychoactive component of the cannabis plant. It has been found effective in treating convulsions and spasticity in patients with seizure disorders, Parkinson’s disease, Tourette syndrome, and autism. It also decreases intraocular pressure and is effective in treating migraines. Studies suggest it may also be helpful in treating anxiety and depression.
As with treating glioblastoma, there are many applications in which THC and CBD should be combined to reach the desired effect. Examples include cancer and neurological disorders, such as multiple sclerosis and muscular dystrophy.
Choosing the Right Cannabis Strain
Although all cannabis plants are, in effect, the same plant, different strains and breeds may be preferred by patients or, in some cases, more effective in treating certain ailments. For example, indicas primarily affect the body; they produce a sedative effect and may be preferred for nighttime pain. Other therapeutic benefits may include:
- Stress and anxiety reduction
- Relief from insomnia and other sleep problems
- A reduction in intraocular pressure
- Management of nausea and vomiting
- Pain relief
- Inflammation relief
- Migraine relief
- Cessation of convulsions
Sativas are known for primarily impacting the user’s thoughts and feelings; it may be preferred for daytime use since it is less likely to cause drowsiness. They may also:
- Promote focus and creativity
- Provide relief from migraines and headaches
- Elevate mood
- Increase the user’s sense of well-being
- Increase appetite
Alternatively, patients who have other medical issues, and those that suffer from both anxiety and depression may benefit more from a hybrid strain. Blends come with a customizable indica-sativa ratio, so patients may need to test various strains to determine their preference.
Everything Medical Marijuana’s Dosing Guide
When first prescribing cannabis to patients, they should always begin on a tincture. This recommendation applies, even if the patient has a previous history of cannabis smoking; ingestion works differently. Studies also indicate that cannabis may adversely react with barbiturates, theophylline, fluoxetine, disulfiram, and certain sedatives and histamines. It should be noted that allergic reactions, although rare, do occur. Symptoms typically include nausea, vomiting, diarrhea, stomach cramping, and other gastrointestinal issues.
Tinctures, which use pure grain ethanol alcohol to extract the plant’s cannabinoids, are the most diluted form of cannabis. As such, reactions and allergies can be easily detected, but with little to no serious adverse effects for the patient. Patients should start with just a small amount and then work their way up to two eyedroppers. Once this tolerance is reached, it is suggested that patients move to canna-caps to reduce their overall medication cost.
Canna-caps, which are capsules that contain decarboxylated cannabis or cannabis that has been heated in a fatty oil to extract the cannabinoids, are customizable to contain CBD, THC, or a mixture of the two. However, the THC content will, in most cases, be relatively low. Still, canna-caps may be effective as a maintenance medication for migraines, depression, anxiety, seizures, and other spasticity disorders.
Patients who suffer from severe or intractable pain are unlikely to reach the desired effects with canna-caps alone. For these patients, canna-caps can be used to build tolerance so that they can eventually move to RSOs. It should also be noted that patients with cancer should always be moved to an RSO; they need whole-plant therapy, rather than just the flower.
RSOs, otherwise known as Rick Simpson Oil, is a highly concentrated form of cannabis. It is preferred to prescribe a whole-plant version that contains ethanol alcohol, rather than BHO, CO2, or flower extract only. The reason for this is due to the entourage effect, which essentially means that all the cannabinoids work together to provide the most healing properties.
RSO may be effective in handling the severe pain and ailments of cancer and chemotherapy, dialysis, multiple sclerosis, muscular dystrophy, and may be preferable in treating pain from a car accident, due to it being less addictive than opioids. Patients should start with a rice grain size, which is equal to one milligram, and then work their way up to a pea size, which is equal to four milligrams. Cancer patients should eventually work up to one milligram, with one-half taken in the morning, and the other half at night.
Breakthrough pain, which is common in conditions that involve severe or intractable pain, can be treated using other various methods of consumption. Examples include traditional smoking, dabbing, vaping, and edibles. Dabbing offers the fastest and most immediate pain relief. However, it can have the same effect on the lungs as traditional cannabis smoking. If this is a concern, patients can be encouraged to either vape or consume edibles, such as chocolates, cookies, or lozenges.
If a patient is to consume edibles, it is crucial that you advise them to consume only one 10 milligram item to start. Inform them that it can take anywhere from 45 minutes to 1.5 hours for the full effect to be felt. As such, they should not consume another edible until at least two hours after taking the first one. Over time, they will learn and discover their tolerance, but slow buildup is recommended and preferred to reduce the risk of overdose.
Treating Children and the Elderly
Although children and the elderly can consume cannabis, and often need it to treat a variety of conditions, some special considerations should be made. The biggest concern is their increased risk of overdose. As such, older patients should slowly build their tolerance, perhaps even slower than younger patients. Children should be given the lowest level of THC possible and should start with an almost negligible amount (0.3 percent). If more is needed, increase the dosage slowly to avoid overprescribing THC.
Monitoring Your Patient
As patients work their way through their cannabis treatment, it is advised that they keep a cannabis journal. Doing so not only helps them to identify which strains and blends are most effective for them, but it can also indicate to you, their physician, when it is time to increase their dosage. It can also aid you in spotting potential adverse effects, sensitivities, or overdoses.
A cannabis journal should include, at the very least:
- Type and amount of cannabis used
- Method of consumption
- Date and time of use
- Mood, feelings, and experience
- Effectiveness at managing symptoms
- Any undesired effects or feelings
Although a cannabis overdose is not fatal, it can produce undesired and potentially severe or frightening effects. The patient may experience a sense of a rapid heartbeat, a decrease in blood pressure, paranoia, dizziness, or hallucinations. If this occurs, recommend that they take a hot shower or bath and rest until the effect wears off. Patients may also seek treatment at an emergency room and receive intravenous fluids if the effect is severe.
Still Have Questions?
Jami Bisi is the owner of Everything Medical Marijuana Magazine and CBD Outreach. She has more than seven years of experience in helping medical patients with their cannabis needs. She offers training and consulting services to other dispensaries that are looking to create or develop medically-geared dispensaries, and she is available to assist physicians who need help determining accurate dosage and application for their patients.