Posted on

cbd dosage for chronic pain

Cbd dosage for chronic pain

CBD won’t get you high the way that cannabis with THC can, but it may still cause side effects. “The most common side effects are fatigue and lethargy, and in rare cases diarrhea,” says Dr. Patel, who notes that CBD that’s taken topically less commonly causes side effects. Topical CBD is best used to address pain in a single joint, rather than widespread pain, she adds.

“There are no standard doses for patients,” says Rachna Patel, DO, a physician who does consultations about medical marijuana and CBD and sells her own line of CBD products. “Ultimately, it’s trial and error, but you have to go about it in a methodical way.”

No two patients respond to CBD in the same way. You and your doctor will probably need to adjust the dose either up or down until you hit the right balance of benefits without side effects. “A lot of it depends on your biochemistry and the way your liver breaks down these chemicals. There’s a wide variety of factors that come into play,” says Dr. Patel.

Here are some tips to guide you on how to find the right CBD dosage for your pain relief and other symptoms.

3. Expect some trial and error

Many factors, such as your body mass index (BMI), specific health condition(s) you have, medications you take, your health history, and the form of CBD you plan to use can influence how much CBD you may need to treat your symptoms. Although CBD is different than medical marijuana — which contains CBD as well as THC, an intoxicating ingredient — a doctor who’s well-versed in cannabis (marijuana) is probably the best person to help you help you sort it out.

Take a look at the label on any over-the-counter pain reliever and you can easily figure out how much you’re supposed to take for your symptoms. Finding the right dose of cannabidiol (CBD) for pain relief, however, isn’t that simple.

“I wouldn’t recommend starting CBD without the supervision of a physician,” says Dr. Patel, author of The CBD Solution. “Many times people purchase a CBD product, try a dose that that doesn’t work for them, switch products and spin their wheels. Or, worse, they develop side effects.”

1. Work with an expert

When it comes to CBD in topical form (creams, lotions, and salves), you’ll probably see the total amount of CBD in the container listed on the label. You’ll then have to divide that total by the number of millimeters in the package to determine how much is in each milliliter. For example, if you have a 50 ml jar of salve that contains 200 mg of CBD, there’s 4 mg per ml. You should then use a metric measuring spoon to scoop out 7.5 ml to get a 30 mg dose of CBD.

Ask your rheumatologist or primary care provider to recommend an expert, or find an expert near you by searching the directory of members of the Society of Cannabis Clinicians or the database maintained by your state’s medical marijuana program (if it has one).

Cbd dosage for chronic pain

Sihota et al. recently examined how to use medical cannabis to support opioid tapering (Sihota et al. 2020). The modified Delphi process was also applied in this report to pragmatically align on how to titrate medical cannabis while reducing the opioid dose. This report differs from the present report as we did not specifically consider opioid sparing but considered all patients living with chronic pain. However, similar recommendations on how to dose and administer medical cannabis were observed across the two studies, i.e., start with CBD and titrate THC for most patients. The main difference between the two studies is that the medical cannabis recommendations for opioid tapering are larger in range, while we have provided three titration protocols that may be used depending on the patient. It is encouraging that two Delphi processes resulted in similar recommendations.

There was consensus for no minimum or maximum age limitation for CBD. Although it was agreed no upper age limit for THC use was necessary, there was debate regarding the minimum age recommendation for THC use, but no consensus was found. It has been reported that the human nervous system is not fully developed until 25 years of age, but different jurisdictions around the world have put varying age limits in place (Arain et al. 2013; Casey et al. 2013). In addition, it is unknown whether treatment with medical cannabis supervised by a physician influences brain development in minors. The recommendation for age limits therefore is to follow the local government regulations and consider the clinical risk-benefit ratio to each individual patient.

When orally administering THC, the pharmacodynamic effects may begin as early as 30 min and continue to rise between 1 and 3 h post ingestion (Grotenhermen 2003; Schlienz et al. 2020). This coincides with whole blood THC concentrations peaking at 1 h (Schlienz et al. 2020). The delay of drug effect when orally ingesting THC and duration of effect are important considerations for patients being treated with medical cannabis. Oral cannabis products (e.g., edibles) are responsible for the majority of emergency room visits related to cannabis intoxication, and understanding when and how long to expect a drug effect may help prevent accidental intoxication (Hudak et al. 2015; Barrus et al. 2016; Monte et al. 2019).

Drug-drug interactions should be considered (Balachandran et al. 2021). THC is a substrate of CYP3A4 and CYP2C9 while CBD is a substrate of CYP3A4 and CYP2C19 (Antoniou et al. 2020) CBD and THC may also inhibit or stimulate drug transporter P-glycoprotein (Zhu et al. 2006). Direct-acting oral anticoagulants all contain warnings to avoid use with drugs that inhibit CYP3A4 and P-glycoprotein. Caution is strongly encouraged when coadministering medical cannabis with direct-acting anticoagulants ( XARELTO® (rivaroxaban), 2020; https://www.pfizer.ca/sites/default/files/201910/ELIQUIS_PM_229267_07Oct2019_Marketed_E.pdf, 2020; https://www.boehringer-ingelheim.ca/sites/ca/files/documents/pradaxapmen.pdf, 2020), warfarin (Yamreudeewong et al. 2009; Yamaori et al. 2012), drugs metabolized by CYP2C19 (e.g., clopidogrel (Kazui et al. 2010) and clobazam (Geffrey et al. 2015; Cox et al. 2019), checkpoint inhibitors (e.g., PD-1 (Taha et al. 2019), and immunotherapy agents (e.g., tacrolimus (Leino et al. 2019). In addition, awareness around the potential reduced efficacy of theophylline and clozapine is important (Cox et al. 2019).

Routine THC dosing and administration

There was consensus that individuals with psychotic disorders, unstable cardiovascular disorders, who are pregnant, who are planning to become pregnant, and/or who are breastfeeding, should avoid medical cannabis, similar to previous guidance documents ([CSL STYLE ERROR: reference with no printed form.]; National Academies of Sciences 2017; Canadian Medical Association 2020). The contraindications associated with medical cannabis are more closely linked to THC, but as discussed, CBD-predominant products may contain THC.

There was consensus that medical cannabis may be considered for patients experiencing neuropathic, inflammatory, nociplastic, and mixed pain. Three treatment protocols were developed. A routine protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg CBD twice daily and titrates the CBD-predominant dose by 10 mg every 2 to 3 days until the patient reaches their goals, or up to 40 mg/day. At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 2.5 mg and titrate by 2.5 mg every 2 to 7 days until a maximum daily dose of 40 mg/day of THC. A conservative protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg once daily and titrates the CBD-predominant dose by 10 mg every 2 to 3 days until the patient reaches their goals, or up to 40 mg/day. At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 1 mg/day and titrate by 1 mg every 7 days until a maximum daily dose of 40 mg/day of THC. A rapid protocol where the clinician initiates the patient on a balanced THC:CBD variety at 2.5–5 mg of each cannabinoid once or twice daily and titrates by 2.5–5 mg of each cannabinoid every 2 to 3 days until the patient reaches his/her goals or to a maximum THC dose of 40 mg/day.

Conservative protocol for medical cannabis dosing and administration

Age ranges

Following analysis of the first two rounds of voting, intended live meeting discussion topics were narrowed down. However, due to the COVID-19 pandemic, the live meeting was converted to a virtual format. Over two virtual meetings, 31 questions were voted on through Zoom Meeting polling software (Zoom Video Communications, San Jose, California, Additional files 4 and 5). The key topics for discussion surrounded the dosing and administration procedures across the different medical cannabis treatment protocols. The other two sections for discussion were breakthrough pain and follow-up recommendations. The task force was encouraged to discuss the question before voting to find common ground if possible.

To address the unmet need for clinical guidance on the safe and effective use of medical cannabis for chronic pain, and to build on previous recommendations from MacCallum and Russo (2018) and Boehnke and Clauw (2019), we developed a modified Delphi process (Dalkey and Helmer 1963; Dalkey 1969; Saad et al. 2019; Oude Voshaar et al. 2019) to establish expert consensus-based recommendations on the dosage and administration of medical cannabis (Fig. 1). 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 (Hasson et al. 2000).