Update by Dr. Orlando Florete, President of AMMPA, Medical Director of Knox Medical, January 29, 2017
As we move forward utilizing medical cannabis as an alternative treatment option, many of our members have expressed deep frustrations with the current 8-hour CME and its lack of dosing guidance. Furthermore, members have come forward with questions as to the labeling and concentrations of the products.
With such a paucity in well-organized high quality research trials, it is especially important to evaluate and treat the patient based on their individualized symptoms and tolerance. Many Florida physicians are starting children with 10-20mg of medical cannabis per day, and adult patients are frequently started in the 20-40mg total per day range. The total daily dosage is typically broken up into two or three separate doses per day. Titrating to desired effect is the next step. Based on the CBD pharmacokinetics, the dosage can be increased under supervision every 5-14 days as necessary.
Dr. Joseph Dorn, former medical director to licensed dispensing organization Surterra Therapeutics said, “I am starting most adults at 10mg twice daily, increasing to three times daily in 10 to 14 days.” Patients symptoms and treatment history may also effect starting dose. “I start patients at 20mg twice daily and increase to three times daily for severe symptoms or with a long history of medical marijuana treatment,” reported Dorn.
Many product formulations are described based on the total milligram content of the bioactive cannabinoid. For example, 600mg of Extracted Cannabis in 30ml of oil is equal to 600mg of THC. Using the provided dropper which results in 0.5mg per drop, a patient would be directed to consume 20 drops twice a day to get the 20mg daily dosage of THC.
Using a vape cartridge that contains 600mg of Extracted Cannabis in 1ml of oil, a patient would inhale 2mg of THC per 2-3 second inhalation. In this circumstance, the patient may be directed to inhale 5 times, twice a day to get the 20mg daily dosage of THC.
Some physicians are already reporting positive results. “We have treated a patient that had a 7-year history of using opioids and suboxone for treatment of severe pain with 24 vape inhalations twice daily (12mg bid), and she has remarkably weaned off of her opioids and suboxone,” said AMMPA member, Dr. Walter Seifert. “That is something I have never seen happen before.”
The form of medical cannabis given to patients is also one of the ordering variables. “The recommended dosing of medical cannabis will vary due to the disease being treated, so too will the mechanism for absorbing it,” explained Dr. Richard Tempel, medical director for licensed dispensing organization CHT Medical. While a longer acting oil or capsule may be ideal for a patient with seizures, someone with severe muscle spasms or breakthrough cancer pain may better benefit from the immediate relief of a vaporizer. Due to the differences in metabolism, one can expect a vaporizer to have an immediate effect and last 1-2 hours, while other oral formulations may take 1-2 hours to notice an effect, but last 4-6 hours. Dr. Tempel also reminds physicians, “It will be up to the patient and physician, through regular dialogue and monitoring, to determine the best form of treatment and individualized dosing.”