To watch the full interview with Dr. Frank, click here.
A DIRECT excerpt taken directly from CBD A Patients Guide to Medical Cannabis: By Lenoard Leinow & Juliana Birnbaum.
Finding the correct dose of CBD for a particular patient is not an easy task, even for experts, because there are so many different factors that play an important part in the patient’s experience.
- The medical condition or problem
- The stage or intensity of the condition
- The patient’s biology and how they respond to CBD
- The patients ECS and how it functions and acclimates over time
- The patient’s body weight
- The patients sensitive to CBD- most important factor
- The patient’s body chemistry, including prescriptions and foods ingested
- How more than 100 different molecules may impact the body
CBD is generally considered safe to consume (as long as it’s clean and has no toxins); however, we use the “precautionary principle” in making recommendations. This principle serves as a guide to making wiser decisions in the face of uncertainty. It guides us to act cautiously in the face of the unknown- “do no harm” and prevent harm- while observing outcomes and making small adjustments over time.
“Titration is a term borrowed from chemistry that means taking small steps over time in order to allow for adjustments slowly. This process lowers the risk of problems such as overdose, overwhelm, or overreaction. We always recommend titration as the best way to introduce CBD to the body. It means starting off on the low side (NO MATTER THE CONDITION) of a dosage range and adjusting upward slowly over time until the desired effect is reached. This cautious approach has served our patients well, and many experts now recommend it as a dosing protocol for medical cannabis.
Since there is a wide range of dosing possibilities, we have identified three dose ranges that are useful for different conditions. Micro dose, standard dose, and a macro (therapeutic) dose. These three ranges, combined with the patient’s body weight, determine the recommended starter dose.
Micro Dose:
- Micro doses are considered a low level of supplement, in the range of 0.5 mg to 20 mg of CBD per dose per day.
- Micro doses can be effective for, sleep, headache, mood disorders, nausea, PTSD, stress, and metabolic disorders.
Standard Dose
- Standard doses are the mid-range, between 10 mg to 100 mg of CBD per dose per day.
- Standard doses have been shown to be effective for pain, inflammation, autoimmune disorders, Lyme disease, anxiety, depression, arthritis, some mental disorders, fibromyalgia, multiple sclerosis, inflammatory bowel syndrome, autism, and weight loss.
Macro Dose
- Macro or therapeutic doses are at the higher range, between 50 mg and 800 mg of CBD per dose per day.
- Doses at this level are often used in cancer, epilepsy, seizure disorders, liver disease, and other severe life-threatening conditions.
You may reach a dose level at which you experience a reduction in the benefit, unpleasant, or a negative reaction. If this happens, step back to the previous dose and continue at that level for at least four days. Then cautiously move up a step again. If your body responds positively to that level, continue at that dose. This is your target dose.
Continue to monitor and record your body’s needs and wants. Adjust as necessary, upward or downward, whenever your body feedback- or your intuition- indicates that a change is needed.
Guidelines:
- There is no such thing as a one-size-fits-all dosing recommendation.
- Consult your physician or healthcare professional and listen closely to his or her recommendation. Discuss the information contained in this book and your own individual needs and preferences.
- Don’t overdo it. In cannabis therapy, we often find that “less is more”. If you are not getting the desired effects, even though you’ve tried raising your dose, try lowering your dose instead. This has helped many people find the “sweet spot”, the best dose range for the particular condition at that period of time. Remember, the sweet spot can move over time. You have to continue to monitor yourself and adjust as necessary.
- Be aware of possible side effects and drug interactions.
- Proceed cautiously, especially if you have a history of alcohol, drug abuse, mental illness, or are pregnant or breast-feeding.
Drug Interactions:
The issue is that CBD is metabolized by cytochrome P450 enzymes, occupying the site of enzymatic activity and preventing it from metabolizing other compounds or pharmaceuticals. Interestingly, components of grapefruit can have the same affect. “The extent to which CBD behaves as a competitive inhibitor of cytochrome CYP450 depends on how tightly CBD binds to the active site of the metabolic enzyme before and after oxidation,” writes Adrian Devitt-Lee a researcher at Project CBD who has studied the topic of drug interactions extensively. "This can change greatly, depending on how, and how much CBD is administered, the unique attributes of the individual taking this medication, and whether isolated CBD or whole plant remedy is used.” This means that patients ingesting CBD products should pay close attention to changes in blood levels of important drugs in their protocol and adjust dosage accordingly under a doctor’s supervision.
“Drug interactions are especially important to consider when using life-saving, sense saving drugs, drugs with narrow therapeutic windows, or medications with major adverse side effects,” Devitt-Lee reports. “In particular, those patients who utilize high doses of CBD concentrates and isolates should keep these factors in mind when mixing remedies”.
It is possible that whole plant Cannabis, with its rich compensatory synergies, interacts differently from the isolated CBD of the cannabinoids that is administered and most research settings.
Dr Frank's personal commentary:
At the end of the day simply put we don’t know all of the interactions especially with specific drugs. To further complicate things most of the research has been done on CBD isolate. It is up to you, the consumer, to monitor your own body’s response.
If something does not feel right speak to your physician about your current medication regimen and its potential interactions with CBD. We do not have the clinical trials to further support any other commentary at this time.
In most cases people will not have an issue. If you are consuming medications previously mentioned proceeded with caution:
- Clobazam or benzodiazepines
- Valproate
- Chemo/ Cancer medications
- Sedatives
- Seizure Medication
- If your medication uses the CYP 450 2C19 enzyme use caution (google this information or speak with a pharmacist). Some of these drugs include proton pump inhibitors including omeprazole (Prilosec), lansoprazole (Prevacid), and pantoprazole (Protonix); diazepam (Valium); carisoprodol (Soma); nelfinavir (Viracept); and others.
- Blood thinners requiring frequent lab testing and follow up
- Individuals with liver disorders
I have seen research indicating that if you are taking a dosage between .5 and 35 mg a day medication interaction is unlikely.
It is fairly safe to say we are primarily concerned with those taking larger servings. A simple solution to this is start slow, monitor your body’s response, and if something doesn’t feel right seek medical attention.
KNOW the medications you are taking and the potential side effects and monitor for those side effects.
We are providing this information to err on the side of caution and spread awareness.
I have yet to see any major news story or article about CBD causing a life-threatening situation with medications (;
People have been using cannabis for a long time with very few issues.
At the end of the day we simply don’t know!!
To sum it all up:
Toxins, pharmaceutical drugs, over the counter drugs, supplements, caffeine, alcohol, and CBD are all broken down by enzymes in the liver. More specifically about 60% of pharmaceutical drugs are metabolized by a liver enzyme called CYP P450. CBD is also metabolized by the CYP P450 enzyme.
CBD has been shown to inhibit CYP P450 activity. The job of CYP P450 is to break down toxins and medications. Generally speaking, if you take one drug that is metabolized by CYP P450 it is easy for the enzyme to do its job. CYP 450 breaks down the medication in a reasonable amount of time and everyone is happy.
But what if you take multiple drugs that all need the same CYP P450 enzyme to break the drugs down. What if both CBD and your medication rely on the same enzyme for metabolism?
If you are taking, for example, a benzodiazepine medication and CBD or a chemotherapy drug and CBD you may be at risk. CBD blocks the P450 enzyme, in turn, it takes longer for your body to break down other medications, increasing (or decreasing) the amount of medication present in the person's blood. This could result in unwanted side-effects or overdose.
Let's use caffeine for example. This is a drug most can relate to. Both CBD and caffeine rely on CYP 450 enzyme for break down. CBD will inhibit the CYP 450 enzyme, which results in a slower excretion rate of caffeine = prolonged effects of caffeine.
As per the current clinical data on pharmaceutical products containing CBD (isolate).
A systematic review in 2014 concluded that CBD generally has a low risk of clinically significant drug-interactions (Stout and Cimino, 2014). A few studies in the current review included examination of drug-drug interactions with CBD. GW Pharmaceuticals performed a clinical trial investigating the pharmacokinetic interaction between CBD/THC spray (sativex) and rifampicin (cytochrome P450 inducer), ketoconazole, and omeprazole (cytochrome P450 inhibitors) (Stott et al., 2013c).
Authors concluded overall that CBD in combination with the drugs were well-tolerated, but consideration should be noted when co-administering with other drugs using the CYP3A4 pathway.
https://www.frontiersin.org/articles/10.3389/fphar.2018.01365/full
Link for A Patients Guide To Medical Cannabis:
*This content is strictly the opinion of Dr. Frank Michalski and is for informational and educational purposes only. It is not intended to provide medical advice or to take the place of medical advice or treatment from a personal physician. All viewers of this content are advised to consult their doctors or qualified health professionals regarding specific health questions. Neither Dr. Frank Michalski nor the publisher of this content takes responsibility for possible health consequences of any person or persons reading or following the information in this educational content. All viewers of this content, especially those taking prescription or over-the-counter medications, should consult their physicians before beginning any nutrition, supplement or lifestyle program.