Optimizing therapeutic cannabis use can be a challenge – for doctors as well as patients. Most physicians never learned about cannabis in medical school. According to a 2017 survey, few feel they are qualified to counsel patients about dosage, CBD: THC ratios, different modes of administration, and potential side effects. "Dosing cannabis is unlike any therapeutic agent to which I was exposed in my medical training," says Dustin Sulak, D.O., the director of Integra Health, which serves patients at offices in Maine and Massachusetts. "Some patients effectively use tiny amounts of cannabis, while others use incredibly high doses. I've seen adult patients achieve therapeutic effects at 1 mg of total cannabinoids daily, while others consume over 2000 mg daily without adverse effects.”

Cannabis comes in many different forms with a wide range of potencies.

Its production and distribution have yet to be standardized in states where cannabis is legal for therapeutic use. So what's the best way to proceed when it seems like cannabis dosage is all over the map? The successful use of cannabis as a medicine largely depends on managing its intoxicating properties. Many people enjoy the cannabis high; for others, it's unpleasant. A person's sensitivity to THC, the main intoxicating component of cannabis, is key to implementing an effective treatment regimen. "The practice of micro-dosing – which entails the consumption of a sub-psychoactive or slightly psychoactive dose of cannabis – is gaining popularity among those who want the medical benefits of cannabis without the buzz.” Cannabidiol (CBD) does not cause an intoxicating high like THC. CBD can lessen or neutralize the THC high, depending on how much each compound is present in a particular product. A more excellent ratio of CBD-to-THC means less high. Today cannabis patients have the option of healing without feeling high.

There are three types of resin-rich cannabis and cannabis products:

Class 1

(THC-dominant) — High THC, low CBD (famously intoxicating cannabis varietals)

Class 2

(THC & CBD) — Mixed THC and CBD cultivars (intoxicating, but not as strong as THC dominant varietals)

Class 3

(CBD-dominant) – High CBD, low THC (non-euphoric marijuana or hemp) There's also a fourth type – those rare cannabis cultivars that prominently express a so-called minor cannabinoid (like CBG or THCV). But in terms of what's currently available for patients, the THC:CBD ratio is paramount and must be considered when formulating dosage strategies.

So, what's the appropriate dosage for each of the three main types of cannabis?

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 not as versatile or as productive 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 versus whole-plant cannabis

Hemp-derived CBD isolates and distillates are already available via numerous internet storefronts. If you're shopping for hemp-derived products online, there can be some quality issues to address before purchasing. 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 people with schizophrenia 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 of antipsychotic drugs. But a follow-up study at Yale University found little cognitive improvement in people with schizophrenia who were given a CBD isolate.

Bereft of the THC stigma (and its therapeutic Moxy), single-molecule CBD recently became an 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 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 20 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 amount 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 the 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 amounts of single-molecule cannabinoids. Human metabolism differs from mice and rats, and animal models' data doesn't always translate to the human experience.

For people as well as pets, cannabis dosage must be individually determined. Several factors come into play, including one's overall health and endocannabinoid tone, influenced by diet, exercise, sleep patterns, day-to-day stress, and genetics. Cannabis is best used as part of a healthy lifestyle.

Some dosage variables to consider:

Cannabis experience

Has the patient used cannabis before? Or are they 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 other 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 neuro-protective 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 useful in minimal 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!"