THE DILEMMAS OF DOSING: Part 2 of 3
In this RYAH exclusive series, “The Dilemmas of Dosing,” we are exploring challenges related to dosing medical cannabis. There is no golden rule, and both patients and providers continue to stumble as they try to find a consistent, accurate, and effective dose.
In this second installment, we look at the popular methods used by patients today: smoking, edibles, and vaping. Each popular method poses unique challenges, especially when it comes to predictability, bioavailability, and consistency. The first step to overcoming these issues of dosing cannabis is more research into the biological mechanisms of the plant itself. The second is improving dose control and trackability through advanced technologies.
If you missed “Part 1: Cannabis Research Fails to Capture Real Patient Data,”, we examined the problems with the available research. Poor quality plant material and challenges with the laboratory setting itself mean physicians have little to go by when working with patients.
In future installments, we will go deeper into the problems of accurately dosing cannabis. Stay tuned.
The Many Challenges Posed by Popular Methods of Consumption
Cannabis patients have more choices than ever before when it comes to consuming plant-medicine. Smoking and edibles, historical options, are now complemented by vape technologies, topicals, inhalers, patches, and even suppositories.
For medicinal applications, the method of consumption has a significant impact on the outcome. Some options are useful for acute treatments, others for long term chronic ailments. No method is perfect; no option delivers 100 percent cannabinoid bioavailability.
New research is deepening our understanding of how cannabis works in the human body. These developments are complemented by exciting new advances in medical technology. Better understanding and better tools will help patients and providers in the quest to reap the most consistent benefits.
Still, patients tend to gravitate towards a preferred method, with smoking still the most popular according to patient surveys. Most research continues to focus exclusively on smoking as a means of consumption, but there is also a growing number of studies into edibles and vaping technology. Here we’ll focus on these three methods, and the challenges they pose for both physicians and patients.
In “The Medicinal Use of Cannabis and Cannabinoids – An International Cross-Sectional Survey on Administration Forms,” 86.8 percent of survey respondents had experience smoking cannabis, with 62.9 percent preferring it (compared to vaping, tea, food/tincture options).
Yet, incineration and inhalation are far from perfect. Even if we look past the health concerns of smoking, smoking almost never delivers consistent doses between sessions, and between patients.
One puff from a cannabis cigarette for one patient is going to deliver different results compared to another – even if all other variables remain the same. This variation also poses problems for the healthcare provider.
Marilyn A. Huestis of “Human Cannabinoid Pharmacokinetics,” has explored this patient to patient variation. Clearly, the therapeutic value is impacted by strain, cannabinoid profile, and incineration temperature, but there are significant differences between patients themselves. As Huestis outlines, “The number, duration, and spacing of puffs, hold time, and inhalation volume, or smoking topography, greatly influences the degree of drug exposure.”
How does a physician prescribe smoked cannabis? Although the norm today is for a provider to prescribe (or recommend) a gram of flower per day, or a few puffs for acute treatment – these are both rough approximations. They say little about precise measurements, required for most modern pharmaceutical preparations.
Edible cannabis has a long history of use for medicinal purposes – from its roots in Ayurvedic medicine to the tinctures prescribed in 19th century Europe. Edibles are a growing segment of the cannabis marketplace, especially in areas with recreational sales. For example, in Colorado, edibles are second only to flower sales. In the US and Canada, edible sales are expected to reach $4.1 billion by 2022.
Edibles look much different today then the tinctures of the past, but they follow the same mechanism of action. Unlike inhalables whose cannabinoids are absorbed through the respiratory tract, edible cannabinoids enter the bloodstream through the digestive tract.
Despite their popularity, edibles pose more risks to patients than other methods of consumption. In an analysis of emergency room visits at the University of Colorado Hospital in Denver, one study has found edibles led to more serious side effects than all other modes of consumption. Commercially available products should come in pre-dosed serving sizes, but as many have found out, it’s easy to overdo it.
Like many other hepatic drugs, the liver metabolizes cannabinoids into entirely new molecules. For example, THC turns into 11-Hydroxy Tetrahydrocannabinol (11-OH-THC). This restructuring affects the experience, possible applications, and potency. Patients fail to understand this increased potency and the interaction with other influences within the digestive tract. It’s why edibles remain one of the most frustrating products to dose.
As the authors if “Tasty THC: Promises and Challenges of Cannabis Edibles” explain, “Factors such as weight, metabolism, gender, and eating habits also contribute to how soon and for how long someone will feel intoxicated following oral ingestion.” Therefore, 10mg of THC for one person is going to feel much different for someone else.
Vaporizing technology, commonly called vaping, comes in second in terms of popularity as per the survey data from “The Medicinal Use of Cannabis and Cannabinoids.” Furthermore, patients gave it, “The highest rating of dose satisfaction (representing “only low dose needed”).”
Vaping is still a relatively new method of consumption. There are few robust clinical studies about the effects, but the preliminary work suggests strong therapeutic potential.
Notably, vaping technology avoids the issues associated with inhalation of smoke into the lungs. Instead of burning organic plant material, vaping heats the plant material through conduction (and/or convention). Patients inhale the vapor, containing the valuable compounds, instead of smoke. With no smoke, vaping is immediately more applicable in the healthcare environment.
Without the necessary controls, vaping still can produce highly variable results between one person and the next. The temperature setting, length of inhale, strength of inhale, and volumetric differences can all mean the therapeutic value for one patient is much different than another. Even the same patient may struggle to repeat the same results between sessions without a dose-measuring device.
The addition of technological controls and measures into the device is what separates recreational vape technology from medical versions. Recreational devices may allow temperature control, but provide little in the way of consistency, accuracy, and measurement of dose — all three characteristics which will be needed to further legitimize cannabis as medicine.
Even lawmakers, historically slow on the evolution of cannabis as medicine, recognise the need for metered dosing devices for the plant.
Improving Therapeutic Value
Medicine must be consistent and predictable to provide the most therapeutic value with the least risk. Consistency, accuracy, and measurement are all crucial concepts in the pharmaceutical industry but (so far) largely ignored in cannabis. As mentioned, Physicians still prescribe cannabis-based on grams of flower per day, and patients continue to rely on the inaccurate method of consumption such as smoking.
The patient, or provider, must have total temperature control, dose management, and detailed tracking tools to ensure a safe and repeatable experience. Providing for these controls helps further legitimize the medicine within pharmaceutical conventions.