Medical Cannabis Dosage Recommendations

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.”

Botox – Not Just For Wrinkle Removal…FDA Approves It For Migraine Treatment

Dr. Craig Amshel, M.D. of Absolute Surgical Specialists, is happy to spread the word about FDA approval of Botox for the treatment of migraine headaches. Botox isn’t just about looking better, it’s about feeling better, and to those that get migraines, feeling better is paramount. Dr. Amshel looks forward to helping people improve their lives with Botox, whether it’s for wrinkle removal, or finding some relief from the crushing pain of migraine headaches.

There are about 3.2 million Americans that suffer from migraine headaches. A migraine is a headache that persists for four to 72 hours and involves sensitivity to noise, odors, and lights. Chronic migraines can be severely disabling to the sufferer and have an adverse impact on work, family, and social functioning. Sadly, many migraine suffers don’t respond well to traditional treatments and medications.

Research on this particular subject has been going on for quite a long time. The FDA has confirmed that Botox shots administered to the head and neck can alleviate and possibly prevent future chronic migraine headaches. To confirm this, the FDA undertook two experiments for 24 weeks each. After the first trial, people who received Botox for migraine were noticed to experience 7.8 fewer headache days and people who received just plain salt water, reported 6.4 fewer days of headache. At the end of second trial, people who received Botox for migraine reported 9.2 fewer days of headache as compared to 6.9 fewer days of the ones who received salt water.

According to the largest study performed to date, presented at the 45th Annual Scientific Meeting of the American Headache Society (AHS), eighty
percent of patients in the study said that after treatment with Botox, their head pain was less frequent, less intense, or both. Compared to standard medications, which can cause a number of side effects, such
as upset stomach, drowsiness and weight gain, side effects from Botox treatment are relatively rare. About 95% of patients in the study reported no side effects.

Researchers are unsure as of yet why Botox relieves head pain. For its other uses — including alleviating wrinkles and treating certain medical conditions – the purified protein relaxes the overactive muscle by blocking nerve impulses that trigger contractions. For migraines, there is no muscle component. Scientists believe Botox works by blocking the protein that carries the message of pain to the brain.

Relief typically takes effect two to three weeks after Botox injections. The longer the treatments continue, the better the pain relief. Study doctors said some patients who had previously overused oral medications were able to stop taking those medications entirely after being treated with Botox.
For more information on Botox for its many uses, or any other way to help you put your best face forward, visit Dr. Craig Amshel at 139 S. Pebble Beach Blvd., Suite 200, Sun City Center, 33573, 813.633.0081 or in Brandon.

Visit Absolute Surgical Specialists online at

Hemorrhoids – Treatment Options

Medications can help relieve symptoms associated with hemorrhoids. Ointments which protect the skin like zinc oxide can prevent injury and reduce itching by forming a barrier over the hemorrhoids. Suppositories used for 7 – 10 days soothes irritation and lubricates the anal canal during bowel movements. Some of these products contain chemicals that can harm the anal tissues if they are used for a long period of time.

Ointments containing hydrocortisone 1% have the effect of reducing inflammation and itching. These products should not be used more than 2 weeks as they can cause atrophy (thinning) of the skin. If inflammation, thrombosis and irritation occurs treatment that is generally recommended is local application of ointments containing anti-inflammatory substances, painkillers or anesthetic substance, suppositories with similar content, and in cases associated with constipation laxatives.

Minimally invasive surgery techniques

Ligation with elastic bands

This process consists of applying a rubber band to the hemorrhoid. Circulation is interrupted and hemorrhoidal mucosa will necrosis (dies). Hemorrhoid is drawn into a tube, then strangled with a lever at the base to be mounted two rubber rings, so that the hemorrhoid dries, because it is not irrigated with blood anymore. After 7-10 days the hemorrhoid falls, leaving a small wound that scars quickly. This procedure is repeated every 2-3 weeks for the other hemorrhoids. This procedure requires no anesthesia.


In this procedure the doctor injects a chemical solution inside hemorrhoids. This method is useful only for small hemorrhoids and is less effective than ligation with elastic bands. The results are often short-lived and require repeated treatment.

Laser photocoagulation

Clots the hemorrhoids and transforms them into fibrous scars. The method is very effective in small hemorrhoids but scar tissue can lead to stenosis or contrary to anal incontinence.

Infrared coagulation. This technique uses a probe that emits infrared radiation and thus produces heat. The probe is applied to the hemorrhoid causing clotting and scar tissue transformation. The method is used alone or in combination with ligation with elastic bands and is considered more effective than laser therapy for treatment of hemorrhoids.

Bipolar coagulation. Electrotherapy bipolar coagulation has a direct effect on the mucous membrane near the hemorrhoid. Bipolar probes are used to treat internal hemorrhoids that bleed.

Galvanic current therapy

Galvanic current therapy is defined as hemorrhoids dissolution (destruction) by chemical means and electrical power supplies using a chemical reaction on the hemorrhoidal mass. The procedure takes around 10 minutes. Galvanic current, completely painless, is applied directly into veins: the current, positive or negative, causes a thermal or a chemical reaction in the tissues, which either destroys or obliterates the hemorrhoidal mass. It is a simple and safe procedure and requires no anesthesia or hospitalization, no sequelae, and does not cause severe complications.

Cryotherapy (extreme freezing). A cryogenic device uses liquid nitrogen to freeze the hemorrhoid. This causes the affected tissue to die, so new tissue can grow in place. This technique has an increased effect when used to treat external hemorrhoids.

Hemorrhoidal artery ligation of branches of internal hemorrhoidal artery with hemorrhoids atrophy as consequence.



Hemorrhoidectomy is surgical resection of hemorrhoids. Hemorrhoidectomy is indicated in case of complications of hemorrhoids like (bleeding, pain, formation of a clot, inflammation of the anus) or while other treatments (sclerosis, cryotherapy, ligation) failed. It is performed under general anesthesia or spinal anesthesia.

Hemorrhoidectomy may be performed as a day procedure, but due to inadequate outpatient care and increased levels of pain after this procedure hospitalization is often required (3 days). Hemorrhoidectomy is the most effective and complete way to remove hemorrhoids, but is associated with the highest complication rate (ano-rectal region pain, temporary difficulty in emptying the bladder, urinary tract infections, etc.).


This procedure aims to reduce blood flow to hemorrhoidal tissue. Patients have less pain compared to those who experienced conventional techniques. Patients can return quickly to normal activities. Hemoroidopexia was associated with a higher risk of recurrence of hemorrhoids and rectal prolapse.

Well, at least I can help you with

Talking about private health issues is part of going to the doctor. Some health concerns, however, feel a lot more personal than others. But whether it’s a sexual problem, hidden rash or body odor, or a debilitating emotional issue, don’t let embarrassment keep you from seeking relief.

Here, in no particular order, are 10 sensitive health problems you can discuss with a health care provider, who won’t be shocked – just ready to help.

1. You have an object stuck in a bodily orifice. It’s probably not a patient’s proudest moment, but hospital emergency rooms routinely deal with sex toys or household objects that become embedded in the body.

While any opening can be involved, “a lot of the objects are inserted into the rectum and get lost there,” says Kate Patrizzi, a clinical nurse specialist in emergency services. “Other objects – a dildo, an ice cream scooper – are really inserted for the intention of pleasure but [patients] can’t get it back out once they’ve put it in.”

If this happens to you, don’t be shy – head to the ER. The staff can medicate you for pain, and they’ll order an X-ray or CT scan to find out just how far the object has gone. They may be able to remove the item then and there, while surgery might be required in other cases.