by Daniel A. Kinderlehrer, M.D.
I have a confession to make. I proposed a talk on medical marijuana at ILADS because it would force me to learn everything I could on the topic. I live in Colorado where it seems there is a dispensary on every corner, and many of my patients have been using medical cannabis. But the huge assortment of products is confusing, and I wanted to give specific recommendations to help patients get the most benefit. Here is what I learned.
Marijuana has 483 phytocannabanoids, which are naturally occurring compounds that can affect many body processes such as appetite, mood and sleep. Most people have heard of one of them—THC, or tetrahydrocannabinol—the psychoactive component of marijuana. THC can make you high, giddy, or euphoric, and provide seemingly awesome universal insights that may appear quite trivial the next day.
Some strains of marijuana now available are not your father’s weed—they have a much higher THC content. It’s important to choose the appropriate strain for your needs, and some people may want to avoid THC entirely. However, it has been clearly established that THC is quite beneficial for pain, sleep, nausea, appetite, and PTSD, so there are medically valid reasons for choosing it.
Most of the non-THC phytocannabanoids fall into the category of cannabidiols, or CBDs. CBDs were once considered to be physiologically inactive unless paired with THC, but it turns out that is not the case. There is compelling scientific research documenting its independent activity, and now there is extensive clinical experience as well.
Did you know that we make our own CBDs? All vertebrates going back 600 million years on the evolutionary tree have an endocannabanoid system, which modulates immune and nervous system function. CBDs are potent anti-inflammatory agents, they regulate neurotransmitters, and they may enhance immune competence. CBDs decrease neuroinflammation and are neuroprotective. They can significantly reduce pain and anxiety.
Marijuana is not the only product that supplies CBDs. Hemp, a variety of cannabis that is used to make rope, fabric and paper, contains CBDs. Hemp has less than 0.3% THC, and is not psychoactive.
There are two strains of cannabis: indica and sativa. Indica is great for pain but is sedating, so it is best used in nighttime. Sativa is activating, can increase energy, and is better suited for daytime use. The difference between indica and sativa is another ingredient, terpenes. Terpenes modify the activity of CBD and THC. There are also a number of hybrid strains now available that essentially cross categories.
If your problem is pain, consider taking CBDs in the form of hemp oil in the daytime. My patients have had excellent responses to a liposomal sublingual extract (taken under the tongue), and it is activating, not sedating. In the evening, you can take a marijuana extract with equal parts THC and CBD, since these together will have additive pain-relieving effects. There are a number of delivery systems available, including smoking, vaping, edibles and sublingual extracts. I recommend the extracts since the onset is reasonably quick, usually in about 30 minutes, and the dose can be easily titrated by adjusting the number of drops under the tongue.
Both hemp-derived CBD and marijuana are available as balms that can be applied topically to relieve pain. Whether taken systemically or applied locally, these products can help many patients significantly decrease their need for pain medication. In fact, states that have legalized medical marijuana have experienced a 25% decrease in opiate overdose deaths. That’s right. This scourge, which took 42,000 lives in 2016 (66,000 including all drug overdose deaths), was significantly reduced by the availability of marijuana.
For sleep, take a THC-dominant indica strain. THC is not only sedating, it increases the time spent in the deeper stages of sleep, so sleep is more restorative. If your problem is difficulty falling asleep, use a short-acting vehicle like vaping, which kicks in within 15 minutes. Vaping is high-tech smoking without the ill effects of the smoke. Alternatively, use a sublingual extract, which has an onset within 30 minutes. Both of these will hang around for up to an hour.
If your problem is staying asleep, then take an edible. It takes 60-90 minutes to get into the circulation, and hangs around for an average of 3-4 hours. I don’t recommend cookies or candy, as they usually have a lot of junk in them—you can take pure THC tablets. The average dose is 10mg, but start with 2.5mg to see how well you tolerate it.
If you have problems with both sleep initiation and maintenance, you can take sublingual extract or vape to fall asleep, and a THC tablet to stay asleep. The table below includes some considerations for choosing among the available options.