Wrong strain right

  Last week a regular patient of mine with a new medical marijuana card made her first trip to a dispensary. They were out of the recommended strains we discussed at her last appointment but it had been a long trip to the dispensary and she was not leaving empty handed. She wasn't leaving with just a few grams either as transportation is often difficult for her to arrange.

Wrong Strain
When she came in for her followup appointment she told me that she had picked up a strain wasn’t working very well for her. Smoking it made her anxiety so bad she could't tell if her pain was better. And that she had invested in a full ounce. Strain choice is very important in not just getting a good result from medical cannabis but also in minimizing side effects. This lady has a pretty significant anxiety disorder and panic attacks. Strains high in THC without the specific terpenes and cannabinoids (both are present in cannabis to various degrees and have effects in the body) to counteract some of the THC's psychoactive effects often make these problems worse. Poor strain choice can lead to intolerable side effects like this and discourage the patient from using medical cannabis and missing out on the advantages the proper cannabis could have possibly provide them. In my patient's case, she knew from our discussions that it was just a wrong strain choice and still wanted to give it another try. But she has a mostly unused container of cannabis medication that doesn't work for her sitting on the shelf, along with all the other bottles of pills and boxes of failed remedies. And she had spent most of her cannabis budget on it.

Making it Right
Should you find yourself in this position, or perhaps the higher CBD strain you need is out of stock, what do you do? Too much unopposed THC is the problem for this patient's anxiety becoming worse. Some conditions require a significant amount of CBD in addition to THC. Her pain issues also require a higher degree of inflammation control than the wrong strain could provide. The answer to making things right is, of course, additional CBD. Timing is Everything Smoked cannabis is in the bloodstream in a manner of minutes and blood levels quickly peak. The levels fall over the next 20-60 minutes. CBD oil is usually administered sublingually (under the tongue). Sublingual cannabis extracts start to rise in the bloodstream after around 20 minutes and can last hours. Knowing this difference in how blood levels change by route of administration is important in timing of your dosing.

CBD should be taken sublingually about 45- 60 minutes before using the high THC cannabis by inhalation. This allows decent circulating levels of CBD to counteract some of the THC's anxiety producing effects. Start with a 10mg dose and judge your response. Double it if anxiety is still intolerable. You will likely have to dose two to four times per day to keep your CBD levels up high enough to avoid anxiety. Develop an Entourage In addition to moderating the psychoactive effects of THC, the sublingual CBD you are taking "creates" a more balanced cannabinoid profile in your bloodstream with the advantages of the entourage effect. If you have an affliction requiring higher CBD strains you can use this technique to simulate the balanced strain you usually use if unavailable and still maintain adequate symptom control. In this case, dose with inhaled cannabis at the time of your CBD dose and 45- 60 minutes later.

Brian Nichol MD
Cannabis Expert