How to Use Marijuana for Common Aches and Ailments

TM How to Use Marijuana for Common Aches and Ailments By Christine Boudreau, M.D.

1 Disclaimer: Revised- July 19, 2018 This book is for informational purposes only. It is not meant to provide medical advice. You should always speak with your primary care provider before taking any medication, herb, or supplement. Purpose of this book: There are many books about the history of marijuana and its use and misuse. There are also many books that address the sociological and legal issues surrounding this ancient plant. This book will not address any of those topics. The purpose of this book is to provide practical information on how to use marijuana as medicine. As a physician who has treated thousands of patients using medical marijuana, I have often struggled to find practical information from the current data available. Despite a multitude of research studies demonstrating the benefits of cannabis and its components, there are few resources that provide specifics. What dose should I take? What is the best method of ingestion for my particular issue? Are there any risks involved based on my medical history? These are just a few of the questions I deal address everyday with my patients. As we continue to learn more and more about marijuana as a medicine, the answers to these questions will continue to evolve. The key is to be thoughtful with how you medicate. Use on the amount and frequency required to adequately address your issue. Use caution with new methods and isolates, as they have not been around long enough for us to know the full extent of their safety or lack thereof. There are risks and benefits associated with each method of ingestion and even with each specific strain. It is important to always start with a low dose and slowly increase as needed, to minimize risk of side effects. Most importantly, always speak with your doctor first before using marijuana. Many patients are afraid of being judged or even admonished by their doctor for using this ancient medicine. However, your doctor can advise you on certain precautions you may need to take. For example, if you are a cardiac patient who has had multiple stents placed, your cardiologist may want to keep your heart rate below a certain number. THC elevates heart rate. Taking a high dose edible could cause your heart rate to exceed the maximum recommended heart rate, putting you at significant cardiac risk. That innocent looking marijuana-infused brownie could potentially be dangerous under certain conditions. NOTE: This book is intended for people who live in a state or country where marijuana is legal and easily available from licensed dispensaries. Please follow your local laws and regulations. Always purchase cannabis from a licensed dispensary or grow it yourself, if you are legally allowed to do so. Never drive or operate heavy machinery while under the influence of this medication. Copyright 2018, Christine Boudreau, M.D. and West Coast Cannabis Tours All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by reviewers, who may quote brief passages in a review.

2 Contents Topic Most Common Mistakes Patients Make Cannabis 101 Methods of Ingestion Potential Negative Side Effects High Risk Patients Drug Interactions Dosing Guidelines What to Take by Symptom Acute pain Chronic pain Inflammatory pain Muscle spasm Abdominal/Intestinal pain Menstrual cramps How to Save Money and Maximize Benefits Medication Log Page 3 4 6 7 9 10 11 12 16 17

3 Most Common Mistakes Patients Make Not taking an important medication because they think they can use cannabis instead. There are a variety of medications that cannabis can replace. If you want to use cannabis in place of your sleep aid, that s fine. However, if you think you can replace your blood pressure medication with cannabis, you will be in for a rude awakening (and possibly a hypertensive stroke). Your primary care provider can better help you understand which medications can be substituted. Trying to wean yourself off of a medication without the help of your physician. When patients on opiates or anti-depressants start cannabis, they often want to wean off of their prescription medications as quickly as possible. However, many of these medications have significant withdrawal effects and must be weaned off slowly. Your primary care provider needs to guide this process and monitor for any symptoms of withdrawal. Taking too much too fast. A little goes a long way when it comes to cannabis. Taking too much all at once (and for some people, that can be as little as 10 mg THC), can result in several hours stuck in a chair or on the floor freaking out because of a THC-induced panic attack. Sometimes that results in a trip to the ER (and if you have insurance like mine, a $6,000 deductible). It s not worth it. Especially when you re just trying it out. Start low (follow my dosing guidelines) and go slow. Driving while under the influence Although most people know not to drive while high, many people do not know when they can safely drive. Swerving tests conducted by UC San Diego, showed significant swerving 3 hours after smoking a joint. (That being said, the swerving was even more prominent in participants the morning after taking a popular sleep aid). Some states have a designated blood level that you must be under, while others rely strictly on roadside tests. Know your local laws. Always wait several hours before driving. If in doubt, take an Uber. Whatever you do, don t take an edible and then an hour later get behind the wheel. As soon as you get on the freeway, that edible will kick in. Leaving edibles accessible to children or pets When people against cannabis argue how bad it is, kids winding up in the ER from their parent s edible is one of their strongest arguments (along with driving while high). Children are amazingly resourceful and if your kid is anything like mine, they can smell out and find any form of chocolate or form of high-fructose corn syrup from 100 feet away. No matter how high the shelf, they will find it and they will consume it. If children are in house, I usually recommend that patients either vape, use transdermal methods, or get the grossest tasting tincture they can find (which is most tinctures). Take the same precautions with pets.

4 Cannabis 101 Cannabis is a plant that contains over 400 unique chemical compounds, each attributing the aroma, color, and effects of the plant. There are two species of the cannabis plant that you need to know about: Cannabis sativa and Cannabis indica. Species Cannabis Sativa Cannabis Indica Potential Benefits Increases: focus, creativity, and energy. It is helpful for patients who need to medicate during the day but do not want to feel lethargic. Relaxes: the body, as well as the mind. It is helpful for those with severe pain, anxiety, and difficulty falling asleep. *Some patients feel a little too stimulated with sativa strains and a little too drowsy with indica strains. For those patients, a hybrid is a good option.

5 There are two cannabinoids that you must know. *There are more, and emerging information is coming out on the uses and safety of them, but let s keep it simple for now. THC (delta-9-tetrahydrocannabinol) CBD (cannabidiol) Psychoactive (can make you high) Non-psychoactive Metabolized by the liver Metabolized by the liver Helps with: Pain Nausea Muscle spasm Decreased appetite Difficulty falling asleep Increased eye pressure (glaucoma) Helps with: Pain Inflammation Muscle spasm (not as well as THC) Anxiety Difficulty staying asleep Seizures Psychosis Neuroprotective CBD and THC play an important role in determining the effect of the other. For example, THC without CBD can cause significant side effects, such as anxiety, paranoia, and even psychosis. CBD without THC is generally not as effective. If you would like to see the impact of CBD on THC in the flesh, so to speak, check out this YouTube video: The Intravenous CBD and THC Experiment. https://yhoo.it/2mtgsrm

6 Methods of Ingestion Reference: MacCallum and Russo. Practical considerations in medical cannabis dosing and administration. European Journal of Internal Medicine. March 2018. *some beverages appear to have onset as rapid as inhalational **an episode of THC toxicity can have effects that last for several days ***As little as 10mg, can be too much for new users. Older patients risk cardiac ischemia due to increased heart rate from THC and either a fall or cerebral hypoperfusion from THC-induced postural hypotension. Note: the recommended inhalational method is a vaporizer or vape pen. Research shows that smoking cannabis (via a joint, etc.) increases risk of respiratory infections and bronchitis. This risk is decreased by vaping. The worst forms of inhalation are bongs and water pipes because the water absorbs THC more effectively than it absorbs the toxins causing users to take in 30% more toxins than if they had smoked an unfiltered joint. CAUTION! Always keep edibles away from children and pets!

7 Potential Negative Side Effects Effect Explanation Drowsiness/fatigue With either indica strains or too high CBD Dizziness THC too high for user Dry Mouth Very common Cough, phlegm, bronchitis Inhalational methods only; lessened with vaping Anxiety Either too much THC or ratio of THC:CBD is too high Nausea THC dose too high Cognitive effects Memory deficits. Pull back dose and frequency and it usually gets better Euphoria Some would argue not a negative Headache Some people get headaches with certain strains; pay attention to which strain caused the headache and avoid it

8 Low blood pressure when standing (orthostatic hypotension) Especially dangerous for older patients. Always a good idea to have someone around the first time you take something new. Wobbly when walking (ataxia) Usually due to too high a dose of THC, which can affect your cerebellum (part of the brain that controls balance). Can lead to a fall. Better to stay seated until it passes (which it likely will). Cannabis hyperemesis Usually due to too much cannabis too frequently over a long period of time. Symptoms are frequent vomiting and abdominal pain, that is magically alleviated with a hot shower. The remedy is to stop using cannabis.

9 Decreased immunity (e.g. AIDS, chemotherapy) High Risk Patients Condition Risk Remedy Infections due to mold or bacteria Elderly Falls (which could cause significant injury) Cardiac ischemia (not enough oxygen to heart) from cannabis-induced tachycardia Mental illness Heavy users have significant increase in development of schizophrenia Increased symptoms of mania and hypomania in patients with bipolar disorders Heavy users have increased incidence of suicidal ideation, attempts, and completion Increased incidence of social anxiety disorder Pregnant/lactating Lower birth weight Pregnancy complications including preterm labor Admission of newborn to NICU There is insufficient data to address later outcomes of offspring Asthma Irritation of lungs from smoking Make sure cannabis has been tested to be free of mold Oral or transdermal methods have less risk than inhalational Elderly patients should always have someone around when they take something for the first time Dose low and go slow Don t be a heavy user. If you have a propensity to become a heavy user, better not to start at all. To avoid psychosis, use higher ratios of CBD to THC, minimizing the overall dose of THC. The increased incidence of social anxiety disorder could be the reason why the people are using the cannabis, rather than the cannabis causing the social anxiety (although THC can cause anxiety, in general). Lower dose and frequency and see if symptoms improve. Do not start using cannabis if you are pregnant or nursing. If you have a significant illness and you have been using cannabis for its treatment for years, discuss your options with your OBGYN. THC relieves asthma-induced bronchoconstriction. You can try vaping. If it bothers you, then stick with oral or transdermal methods. Reference: The Health Effects of Cannabis and Cannabinoids. The National Academies of Sciences, Engineering, and Medicine. 2017.

10 Drug Interactions Oral cannabis is metabolized by the liver. Both CBD and THC can effect the metabolism by any medication you take that is also metabolized by the liver, making it either too strong or too weak. Sublingual administration can bypass the liver but most people wind up swallowing some of the cannabis if it is in tincture form. Sublingual strips may enable you to avoid swallowing the cannabis. Inhaled and transdermal cannabis bypasses the liver, so there should be less of an effect on other medications. However, cannabis can still have additive effects to other medications. For example, inhaling an indica strain and taking a Xanax, would have compounding effects as central nervous system depressants. WebMD has a list of drugs that may interact with cannabis. Remember: Even WebMD is not a substitute for your primary care provider. Your PCP can help you weight the risks and benefits of your specific situation.

11 Dosing Guidelines o Oral Methods: Start with a dose of 2.5 mg THC, CBD, or both every 8 hours as needed If still having symptoms and not experiencing any side effects, increase to 5 mg every 8 hours as needed If needed and tolerated, may slowly increase dose up to 10 mg per dose Do not exceed 30 mg THC per 24 hours as this may increase adverse events without improving efficacy o Inhalational Methods (preferred method of inhalation is vaping): Start with one slow moderate-sized (not deep) breath. Wait 20 minutes. If still having symptoms and not experiencing any negative side effects, may take an additional breath. Always space out inhalational doses by at least 20 minutes. o Transdermal methods In general, dosing is less of a concern with transdermal methods. However, even with topical pain creams you should follow the adage of start low and go slow. When trying a new cream, use it on one small area at first. Wait 4-6 hours before reapplying until you know how long its effects last. Slowly increase the amount of area covered. If you are using a cream or patch that contains THC, do not use any additional forms of THC for 4-6 hours after applying the cream. If you are applying a transdermal patch for the first time, start with the lowest dose available.

12 What to Take by Symptom Symptom Depressed Strains/Methods Oral option: THC edible; if daytime or lethargic, use a sativa. If evening or also anxious, use an indica. If anxious, may also try a 1:1 CBD:THC tincture. Vaping: Strains that uplift the mood include, but are not limited to Granddaddy Purple (a THC-dominant indica), OG Kush (a THC-dominant hybrid), and Harlequin (a CBD-dominant sativa) Anxious Chronic or slow onset anxiety: CBD:THC 1:1 tincture. Starting dose 2.5 mg by mouth every 6 hours as needed. You can slowly increase the dose up to 10 mg if needed and tolerated. Acute anxiety: vape either an indica or a high-cbd hybrid Difficulty falling asleep Difficulty staying asleep Vape a pure indica strain like Granddaddy Purple. The benefit of vaping for sleep is that it s flexible no planning required. Try to go to sleep without medicating. If it doesn t happen, take a hit from your vape pen and a few minutes later you should be out. Another benefit of vaping is that since it is fast on and fast off, if you ever wake up in the middle of the night and can t go back to sleep, you can take a small hit at say, 2am and still be able to wake up on time. A study comparing CBD and THC for sleep found that while THC helps you fall asleep, it is CBD that improves the quality of sleep and can help people who have issues with waking up in the middle of the night. There is some data that suggests that CBD works better at higher doses for this purpose so start with a 5mg CBD tincture or edible about one hour before bed. If that doesn t work, try 10 mg CBD. If you have trouble both falling asleep and staying asleep, you can try these options: 1. Indica edible. 5mg THC to start. Increase slowly (in 2.5 mg increments) to 10 mg if needed and tolerated. 2. CBD edible and then vape the indica as needed to fall asleep

13 Pain Acute Pain Chronic Pain For pain during the day, alternate between a CBD-heavy strain (to decrease inflammation) and a THC-heavy strain (for muscle spasm and as a central pain reliever - blocking the pain signals to the brain). Example of CBD-heavy strains are ACDC and Cannatonic. An example of a THC-heavy strain for daytime pain is Blue Dream (a sativa-dominant hybrid; this will initially relax your body but then give you energy to go about your day). For pain at night as well as insomnia, vape an indica strain like Granddaddy Purple. When vaping take one moderate-sized breath and then wait 20 minutes, allowing the medication to work. If, after 20 minutes, you are still having symptoms and you are not experiencing any negative side effects (dizziness, fast heartbeat), you may take an additional breath. For best coverage of pain, try alternating between CBD and THC. CBD edible or 20:1 tincture. Starting dose 2.5 mg every 6 hours as needed for pain. THC edible (sativa during the day, indica at night). 2.5 mg every 6 hours as needed for pain and nausea. Can slowly increase dosage of both CBD and THC by 2.5 mg increments up to a dose of 10 mg, if needed and tolerated. Oral CBD and THC are both metabolized by the liver and therefore may affect the dose of any other medication or herb that is also metabolized by the liver - making the other medication either too strong or too weak. It is important to discuss your cannabinoid usage with your PCP so they can monitor the efficacy and potential side effects of your other medications.

14 Inflammatory pain For a flare-up of inflammatory pain, try a 2 week course of CBD using either CBD tincture (20:1 tincture or edible). Start with 5 mg by mouth about an hour before bed. If tolerated, increase to 7.5 mg on day 2 and 10 mg on day 3. Continue at 10 mg for the next 10 days then use as tolerated after that. During the day, alternate between CBD and THC using the same method as listed in either acute pain or chronic pain. Topical creams/ointments can also help with inflammatory pain, but is most effective for pain that is easy to reach such as knee pain due to arthritis. Apply a small amount at first and wait at least 4-6 hours before re-applying. Headaches Headaches often respond to THC dominant strains. For daytime use, Sour Diesel and Blue Dream are good options. For evening use, an indica strain such as Granddaddy Purple or Northern Lights may work. Be aware that THC dominant strains may cause anxiety that is dose-dependent. If this happens, decrease your dose of cannabis. For some patients, pairing a small dose of medical cannabis with the recommended dose of an over-thecounter medication provides the most relief with the least side effects. Some patients with frequent headaches or headaches that come with predictability (i.e. those associated with your period), have successfully used CBD to prevent the onset of the headache. Only use this method if you have headaches often enough to justify using a medication daily. Start with 5-10 mg CBD (20:1 tincture or edible) taken about one hour before bedtime. Abdominal/intestinal pain/cramping Menstrual cramps Nausea If you get abdominal pain when you eat, try micro-dosing a 1:1 CBD:THC tincture when you eat. Start with around 1 mg CBD and THC taken by mouth when you eat. Stay at this low of a dose for a week to see if there is an improvement. Theoretically, a CBD-heavy strain should help all your symptoms since CBD (cannabidiol) has anti-inflammatory, anti-spasmodic, and anti-anxiety properties. Examples of CBDheavy strains are Harlequin, ACDC, and Cannatonic. However, some patients respond better to THC-heavy strains. A good THC-heavy strain to try during this time would be Blue Dream, which is a sativa-dominant hybrid. This strain may relax cramps, as well as provide you energy during this time when your energy levels may be low. If you have anxiety during this time or difficulty sleeping, try an indica like Granddaddy Purple or Grape Ape. When addressing nausea, it is important to understand the cause. If you re nauseous because you have a splitting

15 headache, then the best way to relieve the nausea is to relieve the headache. A common cause for people with frequent nausea is anxiety. The most effective way to relieve it? Treat the anxiety. If you are actively vomiting, then the best method will be to inhale the cannabis. It will give you rapid relief and you won t throw it back up. However, if you know ahead of time that you will be nauseous, like you re having chemotherapy this afternoon, take a 1:1 CBD:THC tincture or edible (Start with 5 mg every 4 hours as needed. If needed and tolerated, can slowly increase to 10 mg). Diarrhea 1:1 CBD:THC tincture. Start with 2.5 to 5 mg by mouth (not sublingual) every 4 hours as needed. Smoking cessation If you currently smoke cigarettes, you may be able to use CBD to help you quit, or at least significantly decreased your tobacco usage. A recent study has found that patients who used a CBD inhaler when they had the urge to smoke experienced a 40% reduction in their cigarette smoking after one week compared with no effect seen with placebo. You can apply this by vaping a CBD-heavy strain like ACDC whenever you feel like having a cigarette. Wait 5-10 minutes. If you can go without the cigarette, try to do so. If you still really want it, go ahead and have it. Progress, not perfection.

16 How to Save Money and Maximize Benefits To save money and to ensure preservation of terpenes, I recommend you decarboxylate cannabis yourself. Step 1: Purchase good quality cannabis from a licensed dispensary (NEVER get cannabis off the street as there are reports of people lacing cannabis with other things like rat poison). Confirm with the dispensary that the cannabis you are purchasing has been tested to be free of mold and pesticide. Step 2. Ask the dispensary what the THC and if pertinent, CBD percentage is and write this down. You will use this later to calculate dose. Step 3: Toast the cannabis in your oven at 230 degrees for 45 minutes. This will activate the THC while preserving the terpenes. This process is called decarboxylation. Step 4: You can break it up into a fine powder either by hand or in a food processor. Keep it in an airtight container. Step 5: Calculate your dose. For example, if have a 25% THC strain and you would like to start with 5mg THC, you calculate the amount of cannabis using this formula. 0.25X = 5 mg. Solve for X. Dividing both sides by 0.25, X = 20mg. (Of note, the cannabis loses about 10% weight during the decarboxylation process, so this 20 mg will likely give you 5.5 mg THC, but good enough). Step 6: Weigh out your cannabis on a scale that measures to the milligrams. 20 mg looks like 0.020 on the scale. Step 7: Put your decarb d cannabis in food or drink. If you put it in something that contains fat, you will get better absorption. Absorption without fat is around 20%. 1 gram of cannabis purchased would then give you approximately 50 doses of 5 mg THC (1 gram = 1000 mg. 1000 mg divided by 20 mg per dose = 50 doses). Wow! I thought there would be no math on this test. Good thing there are ready-to-eat edibles available at your local dispensary so you don t have to do this if you don t want to. However, if you are up for the challenge, there are a variety of cannabis cookbooks and recipes available. Feel free to experiment but remember, terpenes start to degrade above 275 degrees. Remember, everyone is different. Just like any medication, there is a bit of trial and error involved in finding what strain and method works best for you. Be systematic. At least in the beginning, keep track of how you respond to specific methods and strains. To help you keep track, there is a sample log on the next page. Every time you enter a dispensary, come armed with questions. The field of cannabis medicine is constantly evolving and there is something new to learn every day.

Symptom Method/Strain/Dose Positive Effects Negative Effects 17

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