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Dosing: “Start Low and Go Slow”

Medicinal cannabis dosing: what is the ‘start low and go slow’ method?

With the current restricted nature of medicinal cannabis prescriptions in the UK, the country is being called upon to become a “leader not a laggard” in the industry amid claims that the current system is failing a multitude of patients.

These restrictions mean that only clinicians listed on the Specialist Register of the General Medical Council can currently prescribe cannabis-based medicines. Such specialists who make the decision to prescribe cannabis-based products must also take into account the relevant NHS Trust governance procedures for unlicensed medicines and the appropriate GMC guidance on the issue before prescribing any products. Additionally, the concerned specialist on the General Medical Council Register should then only prescribe within their own area of practice, with the prescription being subjected to a further review by a multidisciplinary team to fully ascertain its safety.

Unfortunately, even when these limiting stumbling blocks are overcome by the specialist, the process of prescribing medicinal cannabis does not simply become a quick and easy matter.

Creating a rational cannabis care plan for patients is a process that requires much care, as a great number of factors need to be considered in addition to the patient’s condition and outright symptoms.

Factors that should be considered include:

  • Whether the patient has been self-medicating with cannabis prior to treatment (cannabis non-naïve) or not (cannabis naïve)
  • The appropriate method of administration/ cannabis ingestion required to best suit the patient’s symptoms
  • Specific product choice (dependent upon its minor cannabinoid make-up, the product’s batch-to-batch consistency levels and the strain of the cannabis plant used)
  • Whether night-time and/or daytime dosages are required
  • Other drugs and/or herbal supplements the patient is taking
  • The patient’s diet

For most medicinal cannabis care plans, cannabis medicines with a higher CBD level and trace or no amounts of THC are initially prescribed. This is because such medicines are typically very safe, non-intoxicating and have a low risk of adverse side effects. These medicines tend to be very effective, although chronic pain patients often require medicines with higher THC levels over time to counteract their symptoms.

‘Start low and go slow’

As increasing levels of THC may be required by patients over time, an overriding prescription rule is to ‘start low and go slow’. This method involves initially
trying higher CBD formulations before gradually introducing and increasing levels of THC as required to suit a patient’s needs. It is considered best practice to start both cannabis naïve and non-naïve patients on high CBD/low THC products initially.

This ‘start low and go slow’ method overall creates a safe, patient-driven and cost-effective approach to all forms of cannabis-based medicinal products, but few medical methods are without some complications.

Complications

One complication here is that often, after a period of stability with this method, the patient may become less responsive to CBD. This may be due to changes in batch-to-batch variations or other related factors.

Methods which may improve this scenario include having a 48-hour ‘washout period’ before starting the patient on a lower dose. Introducing a small amount of THC may also remedy this situation.

Another complicating factor with prescribing medicinal cannabis generally is that different formulations can deliver different results despite having the same CBD and THC ratios, and similar terpenes. This may be due to the minor cannabinoids in the product, other plant compounds or slight variations in batches. Such complications would have to be carefully considered by the practising medic when prescribing medicinal cannabis to a patient.

Overall, it is clear that many factors have to be considered by specialists when prescribing medical cannabis, as products can vary widely in different ways. The patient’s individual needs and symptoms must also be carefully considered.

Had you heard of the ‘start low and go slow’ method before? Let us know in the comments.

Further investigation and research into cannabis use (both recreational and medical) is thoroughly encouraged by The Academy, particularly through the use of our own online coursesevidence base and whitepapers.

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