Texas ‘medical cannabis law’ (Compassionate Use Act) will take effect in 2017. According to current proposals by TX Governor’s office and Department of Public Safety (DPS), only three licenses will be issued and only small number of patients (hundreds) will be allowed to access medical cannabis. Within the Compassionate Use Act, psychotropic tetrahydrocannabinol (THC) upper level in medical cannabis is set at 0.5 percent. This percentage was set arbitrarily and has little medicinal validity. It is also very close to an already existing legal 0.3% THC level set in foods and food supplements made from industrial hemp, widely available in the US and Texas, including many pharmacies. In the meantime, even more conservative states just recently passed medical cannabis laws that do not set any limits on THC and allow for broader access for patients with diverse un-treatable, terminal, and chronic conditions. Level, or rather the amount of THC to treat distinct medical conditions falls under the competency of the recommending physician, adjusted to individual medical cannabis patient’s needs.
Drugs and dosing is a physician’s responsibility.
In a common scenario, we find ourselves at the doctor’s office; where we often take medical drug prescriptions and recommendations for granted. We rarely ask about long-term effects of these drugs or question the prescribed concentration. In majority of the cases, drug prescriptions are mostly targeting the symptoms. In more complicated medical cases and hard-to-treat or untreatable diseases, drugs are essentially prescribed on a trial-and-error basis. When a physician sees a positive response without significant side effects, the dose maybe increased to achieve the most effective treatment. However, if significant side effects are noted, the drug concentration is either being reduced, or the physician suggests an alternative drug treatment. Furthermore, for untreatable disorders, failures of conventional drugs to control given syndromes lead to prescriptions of cocktails of drugs, or invasive treatments, like chemo, radiation therapy, brain electrode implants, and/or surgery; and, of course, alternative and natural treatments. We see no issues with such a doctor-patient treatment paradigm. This should not be any different when it comes to recommending percentage of medicinal THC.
To achieve most medicinal effects by cannabis, it should be the recommending physicians that set the amount of THC level with their patients’ informed consent and side effect disclosures. To achieve the most therapeutic effect and window, these key points must be considered, and can be abbreviated as ‘CCI’: Condition, Composition, and Intake. Condition represents patients medical history and patients endocannabinoid system state (deficient, THC-dominated, etc.), composition of medicine to be recommended (oil, pills, topical, suppository, etc.), and the route of intake (buccal, sublingual, inhalation, anal, etc.). Just like with pharmaceutical preparations, the chemical composition and purity of cannabis preparations should be available to physicians and patients. Medicinal cannabis treatment and dose/response assessment can be viewed as a cooperative project between physician and patient. Intra-individual and inter-individual differences are inevitable in patients’ responses to cannabis treatments and will be tracked by the recommending physicians.
Most physicians are advised to recommend lower doses, and, depending on results with a given patient, determine the safe and most effective preparation, dosage and way of intake (vaporization, oil, suppository, etc). It should be done on a patient by patient and syndrome by syndrome basis. If patients taking THC experience unwanted side effects, this could be corrected by the recommending physicians. Because, so far, there are no reported deaths from cannabis overdose, this should not present a significant risk to patients. On the other hand, tolerance can develop quickly, requiring increases in level or even concentration of THC to maintain its medicinal effectiveness. To that point even in North Dakota’s newly passed Compassionate Care Act possession for up to three ounces of medical cannabis flower is allowed per every 14 days.
What percentage/amount of THC is therapeutic?
There are many discussions of what really should be the limit of THC for medicinal uses. Nobody really understands why percentage of THC for medicinal cannabis in TX is set at 0.5%. Although there is significant evidence that such low percentage THC preparations combined with cannabidiol (CBD) can be therapeutic, higher concentrations of THC are often required to control intractable seizures, pain, or motor disorder symptoms. In addition, 0.5% THC limit is not much different from hemp THC levels that are set at 0.3% THC nationally and internationally. Even the simple hemp seed oil in the grocery store will have trace amounts of THC. It may be on the orders of magnitude less than 0.3%, but you cannot fully remove THC from the plant that synthesizes it naturally. Any biologists or botanists will tell you that, ‘zero’ does not exist in nature. Thus, it is not clear how much more therapeutic 0.5% THC preparations will be compared to already existing and available hemp products with 0.3% THC limit.
Once again, pharmacist will not tell you to take certain volume of the drug in certain percentage. Rather, a physician will prescribe a total amount of the medicines. Thus, when we get home we do not think of what % of the drug is in the pill or in the tincture. Instead, we take 5 or 10 or 20mg of the active ingredient at a prescribed frequency in either a pill or drop or nasal spray forms. The same should be also done with medicinal THC – the amount of total THC recommended should be used, rather than the percentage strength of the preparation. The main reason for 0.3% THC limit is to prevent adverse effects in individuals who would be mentally fragile or prone to psychosis. This limit was set for daily foods that contain trace amounts of THC, like hemp oil, hemp seed oil, and hemp protein powder. Currently proposed 0.5% THC limit in TX is flawed, because medical cannabis is not a daily (hemp) food, but rather a recommended therapeutic treatment.
Furthermore, Schedule III drug Marinol contains up to 24% of synthetic THC (Dronabinol) in sesame oil and other additives. In a pill form, it contains 2.5, 5, or 10mg doses of synthetic THC. Psychotropic effects of Dronabinol can last up to four hours and the maximum dose typically does not exceed six doses (60mg)/day. How does this amount compare to THC in cannabis flower?
Typically, medicinal cannabis (high THC cannabis) contains anywhere between 5 and 30% of THC. So if one were to take median cannabis flower with THC concentration of 15%, one gram of cannabis flower would contain 150 milligrams of THC. One gram of cannabis flower can make 1.5-2 cannabis ‘joints’. So for 15% cannabis split in two joints, each would contain 75 mg of natural THC and other cannabinoids. One has to keep in mind that synthetic cannabinoids, like Dronabinol can be multitude times more potent at binding CB1 receptors than the natural THC from cannabis flower. Cannabis flower will also contain other phytocannabinoids and molecules that may work in synergy. For some individuals and syndromes, 10 mg of synthetic or natural THC is sufficient to achieve a therapeutic dose. While for the others, this dose may have to be tenfold higher. This depends on the route of intake and individual metabolism. Thus, this is a complex field and final decision on what amount of THC or what ratio of THC to CBD is therapeutic should be left to the recommending physicians. In the meantime, Texas physicians should indulge in understanding the science of the cannabis plants, cannabinoids, and the cannabis entourage effect.
Oh, Cannabis! Our closest ally to the North – Canada allows their veterans to have up to 10 grams of subsidized medical cannabis/day. Oh, boy!
What else in cannabis, besides THC, has therapeutic potentials? Individuals – need individual doses and strains. Thus, percentage of THC, or CBD, are not the only determinants in how effective certain cannabis oil will be on a given patient and/or syndrome. Cannabis plants contain over 1000 compounds. Many of these compounds, including the aromatic terpenes, flavonoids, and omega amino acids have their inherent therapeutic properties. Botanical cannabis preparations, like oils, contain hundreds of compounds with inherent therapeutic properties and have been used as medicine world-wide for thousands of years. Thus, it is the sum interaction of multiple active ingredients that can create therapeutic synergies and increase the therapeutic effectiveness. This is called ‘cannabis entourage effect’ and it is mostly thought to have positive effects. However, synergy in compounds can also lead to negative or adverse effects, which can be corrected by a different strain or preparation or route of intake, yet maintaining the same effective level of THC, CBD, and other known active ingredients.
Short history of Texas medical cannabis law. Let’s briefly review the short history of the medical cannabis in Texas. When the Compassionate Act was raised in 2014, it was based on a need to access medical or food supplement grade oil made from industrial hemp, containing cannabidiol (CBD). Subsequently, ‘CBD oil law’ became obsolete as hemp-based products and hemp oil containing CBD, and natural CBD isolates dissolved in other carriers oils are widely available throughout the country and in hundreds of health stores and pharmacies in Texas. [Hemp food and food supplement products can contain up to 0.3% THC.] Since, medical cannabis acceptance grew at an exponential rate in the US and world-wide, Texas’s Compassionate Act Law became somewhat similar to Medical Cannabis laws in other states, but with a very limited access and 0.5% THC limit. After Nov. 8th Presidential election, 60% of the US population now has access to legalized cannabis.
Medical cannabis (em)migration. Hundreds of families moved away from other states into Colorado and California for medical cannabis. Texas’s proximity to Colorado has resulted in many families and individuals moving to Colorado, or spending a portion of their time there (or obtaining these treatments illegally from the surrounding ‘legal states’). Despite the bipartisan national acceptance of cannabis, Texas laws remain constricting. TX patients, however, will now have plenty more states to choose from to relocate for their medical needs. Compassionate laws with broad access, dozens of licenses and few limitations on concentrations of botanical ingredients will allow for Texas to ‘do it right’ and prosper; fostering further benefits for the society, attracting more domestic and foreign businesses, and promoting positive economic growth.