Edible Errors

Title description, April 7, 2014

"Edibles" is the catch all word for orally administered cannabis. Orally administered cannabis is different from inhaled cannabis in ways that give it certain advantages such as increased potency and a longer duration of effect. It also has some disadvantages which can make it a bit difficult to use.

Differences Between Inhaled and Ingested Cannabis Inhaled cannabis is very rapidly absorbed into the bloodstream and distributed to the body. Effects and peak levels of cannabinoids in the blood occur in minutes. This almost immediate effect makes it easy to titrate, meaning administering small doses until the desired effect is achieved. It is relatively easy for a patient to get the dose correct. The effects of inhaled cannabis tend to dissipate within an hour.

Edibles are ingested and digested. The absorption of substances from the gut, of course, takes longer. It can also be quite variable in patients with peak blood levels and effects usually take from 1-4 hours to take effect. In some patients it may be even longer. Orally taken cannabinoids are more potent than inhaled versions. After gut absorption into the bloodstream, THC is metabolized to a different form in the liver before being released into the circulation to the rest of the body. This form is much more powerful than the inhaled form that is immediately released into the circulation and is longer lasting.

Thinking About Edibles
Well, it seems that edibles are the way to go for patients with chronic, constant pain. Long lasting relief to improve functioning is the main treatment goal- break out the gummies! Not so fast there, pilgrim... I usually recommend patients only start orally administered cannabis products after they are used to the side effects of cannabis and have become "tolerant" by the inhalation route. This is important because of the advantages of the high potency and long duration of action become disadvantages if the patient takes a dose that has a larger than anticipated effect. Instead of being "over treated" for an hour the effects can last the better part of the day. Sure, the pain symptoms may be gone but the side effects of cannabis over treatment impair daily activities. Patients will experience less intense side effects if tolerant.

Edible Dosing and Titration
Tinctures are really the best route to transition to oral cannabis. A tincture is an extract of cannabinoids using an ingestible solvent such as grain alcohol. When administered under the tongue, absorption into the bloodstream and distribution to the liver is rapid. Instead of the hours for edibles to be absorbed from the gut, the tincture delivered sublingually works in about 45 minutes. This makes titration of dose which relieves symptoms but minimizes side effects relatively easy. Tinctures are covered in more detail in a following blog. The more commonly available gummies and candies are different. Tolerant patients taking their first edible dose of cannabis should really plan a day to thoughtfully begin their titration. Commercially available edibles are usually available as a specified dose of THC with or without a specified dose of CBD. The THC and CBD combination will likely have fewer side effects. THC alone can produce or worsen anxiety and paranoia and the addition of CBD will help to minimize this effect. I encourage patients to take notes on their first titration for two reasons. First it makes one really focus on their pain levels. Second, most tolerant patients will find that relief of their pain symptoms occurs before the psychoactive effects. This is the endpoint we are looking for- the sweet spot of symptom control without impairing side effects. Doses should be small, about 2.5mg. I suggest around a two hour interval between doses for most patients. The dose is given every dosing interval until the endpoint is reached. After that, the patient should pay close attention to how long the effects last. If two doses of 2.5mg reach the endpoint and it lasted eight hours, the patient can essentially put themselves on a scheduled dose of 5mg three times per day.

Quick Start Guide
This has just been short introduction to orally administered cannabis focusing on the commercially available edibles currently available in Arkansas dispensaries. Discussion of other forms and preparations of oral cannabis will roll out as they become available. If you are going to give them a try, the advice above should help you achieve the response you are seeking. Remember, "start low and go slow" with edible cannabis.

About CannabisExpertMD

Cannabis as a medicine seems quite new. With a majority of states now allowing its use, patients, many of their doctors, society at large and certainly to law enforcement and government are searching for information. The information available online is vast and often confusing. Much of it is incomplete, far too detailed and technical for most people to sort through, clever marketing or just plain wrong.

Medical cannabis patients are certified by a physician as having a qualifying condition. The patient is issued a card and then, too often is left to decide for themselves as to the best treatment. Dispensary employees are usually the cornerstone of giving patients advice on strains and how to use cannabis. Sometimes they are very good at giving recommendations. Sometimes, not so much.

Modern medicine treats disease with the drugs that are effective for the majority of patients, forgetting that we are all very different individuals. What is a good choice for one patient may be ineffective or cause side effects in another. Although most patients see some improvement in using cannabis, getting the best result is a bit more complicated...

I have seen patients without much knowledge or direction experience lukewarm results of medical marijuana. I have also seen those so-so results turn into remarkable improvement under the knowledgeable direction of a doctor that treats the individual patient using the correct combination/forms/amount of cannabis.

It is my hope to sift through all the noise, marketing, agenda driven studies, politics and stigmas encountered when one tries to be an informed medical cannabis patient. I want you to get the best result from medical cannabis you can.

Brian Nichol MD
Cannabis Expert

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