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New Dosing Recommendations for Targeting Pain with Medical Cannabis

Despite hundreds of thousands of patients legally using medical cannabis to treat a broad spectrum of conditions, it remains frustratingly difficult to dose. There are no official guidelines or dosing schedules. In large part, patients experiment independently, with information found online or based on vague suggestions from friends.


Physicians, researchers, and lawmakers have struggled to craft policies around cannabis dosage guidelines. But, as medical cannabis earns more acceptance across the national and international health care community, there have been renewed attempts to settle on safe and standardized dosage recommendations.


Why Dosing Recommendations for Medical Cannabis Are Challenging


As discussed in RYAH’s Dilemmas of Dosing series (Part I, Part II, Part III), dosing protocols have continued to evade continued to elude physicians and researchers alike. 


First and foremost, cannabis is a highly variable plant. From one cultivar to the next, and often from one plant to the next, the cannabinoid and terpenoid profiles vary. Blanket prescriptions for one gram a day, as is still the case in some markets, fail to consider the dramatic differences between plants.


Secondly, there is significant variability at the patient level. Age, sex, body mass index, condition treated, and a host of other factors influence tolerance level and effective dose size. Even if the conditions are the same, the dose that works for an older man will not work for a younger woman. 


Thirdly, the method of consumption significantly impacts absorbed dose. Most patients still prefer to smoke or vape medical cannabis, even when other options are available. 


Natural inhalation, whether from a vape, inhaler, or joint, is highly variable from one person to another How much a person inhales can even change during the same session. When it comes to edibles or other oral preparations, absorption is further frustrated by unpredictable changes in metabolism, digestion, and genetics. 


With so many challenging variables, medical cannabis doesn’t fit within the controlled world required for conventional clinical trials. Unfortunately, this means a widely accepted medical cannabis dosing regimen has failed to materialize. 


A Renewed Attempt to Standardize Medical Cannabis Dosing


Considering the number of people seeking access to medical cannabis, patients, physicians, and professional organizations are all seeking clarity on an effective and safe dose. 


Dosing recommendations vary from one organization or study to the next. But, the end goal has always been the same: to safely reach an effective dose, with the minimal number of adverse events. As was highlighted by the Canadian Pharmacists Association document, “Finding the right therapeutic dosage is a very individualized process for each patient!”


One of the most recent attempts to create a clear, scientifically supported dosing recommendation came from a team of over 20 cannabis experts in “Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process,” published in July 2021.


For the first time, researchers applied the Delphi process to reach a dosage consensus for a specific condition — chronic pain. As they explained in the paper, “The modified Delphi process has been used extensively in health care settings to provide consensus-based recommendations on important clinical questions where randomized control trial data is lacking.” It seems perfectly suited to the current environment of medical cannabis.


After several rounds of voting, the “global task force” created three separate dosing protocols: routine administration, conservative administration, and rapid administration. Each is designed to ease a patient treating chronic pain into medical cannabis and treatment with THC if needed.


Routine Protocol


According to the recommendations, most patients would fall under this routine dosing protocol. Under this recommendation, all patients begin with 5 mg from a cannabidiol (CBD) dominant strain, delivered twice daily. 


Over the next two to three days, the patients increase dosage by 10 mg a day up to 40 mg of CBD total per day. Increases only occur if the desired treatment goals have not been reached and there have been no adverse effects. 


Once the patient reaches 40 mg of CBD, the physician introduces 2.5 mg of THC per day. Then, increasing by 2.5 mg of THC every two to seven days, until a maximum dose of 40 mg per day is achieved. Under these recommendations, the patient continues taking 40 mg of CBD at the same time. 


Conservative Protocol


For those patients who may have some complications (for example, clinically frail patients or those with complex comorbidities, polypharmacy, etc.), a more conservative approach may be needed. 


As with the Routine Protocol, patients should start with a CBD strain but only 5 mg total per day. Then, they recommend increasing the daily dose by 5 to 10 mg over several days until clinical goals are achieved or the patient reaches a maximum daily dose of 40 mg of CBD.


Patients may then take 1 mg of THC daily, increasing by 1 mg a week until goals are achieved or the patient reaches a maximum daily dose of 40 mg of THC. 


Rapid Protocol


Both the routine and the conservative approach could require many months of slow titration. But, in some circumstances, a patient may need a more rapid treatment protocol. As per the consensus using the Delphi approach, this may happen with “severe pain, palliation, and for those with significant prior use of cannabis.”


Under the rapid protocol, patients may begin with a balanced THC:CBD ratio, either with 2.5 or 5 mg each, administered twice daily. The guidelines suggest titrating every two to three days, by 2.5 to 5 mg of each cannabinoid delivered twice daily. The maximum recommended dose for daily THC remains 40 mg.


Execution of Medical Cannabis Dosing Guidelines 


Dosing guidelines like those above published in the Journal of Cannabis Research are just one half of the equation. The other half is the delivery mechanism. 


Patients need a reliable way to receive consistent and measurable doses, to adhere to their treatment protocol. Physicians also need a way to monitor patient titration and dose size.


RYAH Group’s suite of precision dosing devices offers a practical way to safely execute these new dosing guidelines. The RYAH Smart Patch, Inhaler, and Pen give patients and physicians control over the medicine, the dose, and the protocol. Detailed analytics help determine what dose size is working, what needs adjusting, and a patient’s progression toward their treatment goals. It’s the data-driven approach to plant-based medicine desperately needed to help patients reach their goals faster.

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