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CBD DOSING: WHEN IS LESS… MORE?

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Just when I thought I had cannabis dosing down to a science, I find myself in a quandary.

When the philosophy and foundation of my practice is based on the science of whole-plant cannabis, how do I dose single-molecule CBD (distillates and isolates,) or other non-whole plant cannabis?

Consider the Evidence

It is established and accepted that the dosing for Epidiolex (pharmaceutical CBD isolate prescribed for seizure disorders) often ranges up to 400 mg or more daily.(1)  However, a study from 2015 clearly shows a contrast between the level of efficacy using a whole plant product versus a CBD isolate.(2)  From this study alone, we can begin to see that whole-plant cannabis very clearly proves to be more effective at much lower doses.

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For nearly eight years, I have treated over five hundred seizure patients, recommending a dosed protocol of whole-plant cannabis. In general, the majority of the children have responded very well, and at a considerably lower dose than that of Epidiolex. In fact, I have very seldom recommended more than 100 mg of whole plant CBD as a daily dose. 

Perhaps one-third of the patients also require THC-Acid, as well as modest amounts of THC.  Soon, we will be adding THC-V into the mix, which we feel confident will show even greater efficacy.

Most likely, tinctures will eventually contain four components: CBD, THC-A and THC-V, with a modest amount of THC will be the extracts of the future in treating seizures. However, in order to achieve this multi-drug therapy, whether for seizures, pain, nausea, cancer, etc., cannabinoid dosing must be safe and reasonable. This remains quite a challenge with pharmaceutical medications due to their higher level of side effects.

So what is a “reasonable” dose?

In my opinion, the lowest possible dose of effective medicine with acceptable adverse reactions would qualify as a reasonable dose.

Single-molecule cannabis (distillates and isolates) requires hundreds of mgs of cannabinoids to be effective, and even then, it is simply less effective by comparison to whole plant. Additionally, it has more side effects and has increased drug interactions with any drug metabolized by the liver.

What concerns me the most?  The increase in drug interactions.

When CBD is surrounded by hundreds of other cannabinoids, terpenes, flavonoids, plant wax, plant lipids and more, found organically in the whole plant, it works as nature intended it to. Why reduce it to a single molecule?

It seems arrogant to think that nature and evolution developed a plant that is less than perfect in its entirety. How the distillate/isolate business is flourishing is beyond me. I surmise that it’s flourishing because CBD is at the height of its popularity at the moment, and unfortunately, due to the lack of education on the part of many health care professionals, the retailers, and the consumers, any CBD product is felt to be acceptable.

Buyer beware:

1. All CBD products are definitely NOT created equally!

If anyone doubts the huge difference between single-molecule and whole plant, try 5 mg of each, individually, under your tongue. If you find the single-molecule to be more effective, I would like to take you to lunch and discuss it. I have tried it myself many, many times and there is just no comparison.

2.  More is not necessarily better:

When researching products, if you come across a CBD tincture with 1,500 mg, it’s not necessarily a “good deal.” It is likely high in mg due in part to marketing strategies. It’s easy to see why this is the trend. For one, growing plants is a LOT of work and requires a good deal of real estate. Furthermore, ordering wholesale bottles online is convenient, and it can easily be “white labeled” and distributed cheaply.  Bottom line… higher yield, lower production costs. 

3.  Do the Math: Quality may cost less!

Even so, you might argue that the deciding factor in making your purchase is the cost, and distillates/isolates are less expensive. Don’t forget, as I mentioned earlier, distillates/isolates require a much higher dose to show any effectiveness.

Will it really be less expensive when you consider how much you’ll need to take?

4. Safety. 

As we know, CBD is deemed “safe,” so what’s the concern? The concern is that many patients using single-molecule products take hundreds of mg of CBD per day, as well as being on several pharmaceuticals.

When I advise whole plant CBD, the average dose my patients take is under 50 mg daily. Doses in the single digits or very low double-digit range very, very rarely interact with other pharmaceutical drugs. Most of the seizure patients in my care are on 1 or 2 other anti-seizure medications and are getting their levels checked. Their drug levels have never changed, suggesting minimal or no drug interactions.

Case in point:

A patient came in recently who had been taking 200 mg of a CBD isolate. He was also on lithium. For the first time in ten years, he became lithium toxic. With my guidance, he discontinued the CBD he had been using, and he improved. He is currently on 45 mg of whole plant CBD, no lithium, and doing well.

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My Biggest Concern

Very concentrated isolate preparations are sold in local markets for every conceivable medical condition. I despise seeing these “profit only” efforts.

I stand by my belief that whole-plant CBD is incomparable, unparalleled, and clearly the far superior medicament. I am very concerned that as higher and higher doses of distillates/isolates are used, we will begin seeing more drug interactions.

If this happens, what sort of risk does this pose for the future of medical cannabis?

Take Home Message

When the dust settles, I want to be on the side of the “smelly cannabis plants.” I want to be on the side of “whole plant medicine.”

If you love the plant as I do, please don’t isolate it. Use the whole plant.

To learn more:

(1) https://www.epidiolex.com/seizure-reduction-and-risk-information

 

(2) http://www.scirp.org/pdf/PP_2015021016351567.pdf

Author
Allan Frankel, MD Dr Allan Frankel is one of the few physicians in the US who truly understands Cannabis as a medicine. All treatments suggested have been well studied. Every patient seen by Dr Frankel is given a personally created Treatment Plan created with the patient's specific issues defined. Plant medicine requires "tuning" of the dosing. Dr Frankel works with his patients thru a messaging portal. The use of this portal, allows quick and simple follow up contact with Dr Frankel. Patients are not charged for these messages, as this is how Dr Frankel has learned what he has learned. Follow up appointments in person or by phone/video are also available when needed

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