03/03/2022
This is an insightful read and great information 👩🏼🍳✌🏼
Cannabis Dose Titration- Edibles
Orally consumed cannabis (edibles) are a convenient, discreet and familiar way for patients to consume cannabis. Edibles are usually more potent and longer lasting than other routes of administration. This makes them advantageous for patients who require long lasting effects and/or high dose ranges. The ability to produce edibles from flower at home can make them much more cost effective for such patients. Edibles can also be the most complicated way to consume cannabis with predictable results.
Patients new to cannabis should consider using the inhalation route of administration to become tolerant to the side effects of THC (being “high”) before pursuing tinctures or edibles for longer lasting symptom control. If a novice patient consumes an edible and finds the euphoric effects of THC too intense, the high may last several hours creating an uncomfortable situation and possibly discouraging the use of cannabis as a medication.
Edibles
Edible cannabis is available in a variety of forms, the most common being chocolates, candies and baked goods. Those available at dispensaries will be of a consistent dose which will appear on the label. Home baked goods will vary greatly in potency, although skilled patients can learn how to produce products of known doses to produce consistent effects. It is suggested to start with commercially prepared edibles to determine more accurate dosing.
Orally administered cannabis passes through the stomach into the intestines where it is absorbed with other food. Everything absorbed into the circulating blood from the gut first travels to the liver before being released to the rest of the body where it exerts its effects.
The form of THC patients are familiar with experiencing from smoking or va**ng is delta-9-THC, the same form of THC contained in edibles; however, before the delta-9-THC is released in the circulation, some is metabolized to different forms of THC. A relatively modest amount of the delta-9-THC passes through the liver intact. A large proportion of it is changed into the inactive form of THC (THC-COOH) and a relatively high amount is metabolized to 11-OH-THC, a more potent and longer lived “species” of THC.
It has been well documented by 19th century physicians of the difficulties with oral administration. Under dosing resulting in inadequate symptom control and over dosing led to side effects and tremendous variability in patent responses was observed. Talk to any patient who has used edibles and most will say they are hard to predict as to “when they kick in, how hard they hit and how long they last.” This characteristic of edibles can make them difficult to reliably use.
The reason for this variability in effects is because cannabinoids are not water soluble. This is why tinctures are usually oil or alcohol based and edibles often contain contain a good amount of fat. Consuming a 10mg gummy from a dispensary on an empty stomach results in most of the delta-9-THC passing through the GI tract unabsorbed. The same 10mg gummy consumed with a fatty meal results in the delta-9-THC becoming bound with the fat and much more is absorbed from the gut. This results in a much larger amount of 11-OH-THC being produced by the liver and the more potent and usually longer lived effects observed using edibles compared to other routes of administration.
After oral ingestion, the effects of THC typically set in after 30 to 90 minutes with maximum psychotropic effects (feeling high) occurring in several hours lasting 4 to 12 hours. These are obviously very general observations and only by careful titration can edible doses and timing be determined for each unique person. Patients with gastroparesis (slow stomach emptying, occurs often in diabetics) and prior bariatric surgery often find consistent edible dosing challenging.
Initial Edible Titration
The variable effects edibles produce in individuals requires an initial titration to get an idea of a well tolerated dose. Ingesting a large dose of cannabinoids orally can result in prolonged euphoric effects. As with all initial titrations, do it on a day you have no other plans or commitments. If you “over serve” yourself using edibles, you will of course be fine, but you may be quite high for hours.
Be sure to consume some fat containing food shortly before ingesting the edible. This will improve the absorption of cannabinoids from the gut. Be consistent in what you eat when doing the titration as changing your diet may change cannabinoid absorption.
Record symptom intensity, food consumed and time in your journal (as we have previously covered). The initial dose should be 2.5 to 5.0mg for novice patients and 5.0 to 10mg for patients with some experience using cannabis. Start at the lower side of the dose range. Record symptoms, euphoric and any other side effects every 30 minutes. Do not dose any additional edibles for two hours at which point most patients will feel maximum euphoria, the primary limiting side effect of THC. If you have not had adequate symptom improvement and do not feel too high, consume another dose of edible- have a snack with it. Record your response every 30 minutes, dose in two hours again if needed. On this initial titration you will find the dose at which you see some symptom improvement without feeling too high. If two 2.5mg doses of edible cannabis relieves your symptoms, your initial starting dose would be 5mg. If you do overshoot your target as far as side effects, the last well tolerated total dose recorded in your journal will be that which you should consider for your week long titrations.
Week Long Titrations
The dose you have determined to show some symptom improvement and tolerable side effects is your starting dose. Keeping a detailed journal is required to perform an effective titration. Edible titrations are usually performed for treating long lived symptoms like arthritis, anxiety, peripheral neuropathy, fibromyalgia, etc. and are performed over about a week. Use the dose you determined to show some effectiveness with tolerable side effects in the initial titration as the starting dose. Initial time between doses can be twice/day, about every 12 hours. Do this for a week and review your journal. If symptom control with the dose is inadequate, increase by 25% to 50% and use the edible at this dose for another week. If symptom control is adequate but not lasting 12 hours, keep the dose the same and change dose interval to every 8 hours. Do for another week… Repeat this process until you have determined the dose and time between doses most appropriate for yourself which treats your symptoms or you have found the maximum dose tolerated without experiencing side effects.
Remember it is symptom control which is the objective. Euphoric effects are a side effect- be careful not to confuse feeling high with improvement in symptoms. Medical benefits are usually experienced before euphoric effects in THC tolerant patients.
A deliberate and disciplined approach using the titration method will help you determine the lowest, most effective dose of cannabis to treat your conditions. This of course results in a better result for you and also has the benefit of saving you money- the lowest effective dose is the least expensive.
