An Editorial by Dr. Raquel Peyraube
Continuing with the discussion on general aspects of cannabis and cannabinoid treatments, let’s look at two practical issues when implementing them.
The effectiveness of a drug treatment is dependent on several factors, one of them being the amount of active ingredient that will reach the sites where we want it to have the desired effect. This is called bioavailability. The bioavailability depends on several factors, and in the case of oral ingestion, a big factor is the amount of the drug that will be absorbed by the digestive system.
In the case of cannabinoids, the oral bioavailability is low compared to the bioavailability when the medicine is inhaled. However, since the effects of the cannabinoids typically last longer when consumed orally, oral ingestion continues to be the best method for chronic illnesses.
Cannabinoids are fatty compounds that are generally formulated as oils. To improve absorption through the digestive tract, it is recommended that doses be consumed 1 hour and 30 minutes (before and after meals) and are accompanied by a portion of fatty food. Examples of such foods are avocado, peanut butter, chocolate (preferably white), fatty cheese (Gruyere, Emmentaler, blue cheeses), milk or yogurt integers (not fat-free) and coconut oil (among others).
Patients with digestive intolerance to cannabinoid oils (where other methods of delivery such as soft capsules, tablets or patches are not available) can try to improve that intolerance by taking medication with meals. In this case, there will be a lower availability of the active substance, and the patient may require slightly higher doses.
A commonly asked question when beginning cannabis-based treatment is: How will this medication affect my other medications? Is the introduction of cannabinoids compatible with traditional medications? This is an important issue to discuss with your doctor.
In my clinical practice, for example, I ask the patient to fill out a form with all the medication he/she takes, indicating the active substance and the dose. From that list, I lay out a plan for each different medication, taking the patients’ medical history into account. This plan is dependent on the types and doses of other medications, as some medications do not interact favourably with cannabinoids. In these cases, the traditional medication may have to be lowered in dose, or changed, to achieve the desired effect from the cannabinoids. A synergistic relationship can occur between medications (for example opioid analgesics and cannabinoids), and it may involve changing the dosage of each medication to find balance. This synergistic relationship between opioids and cannabinoids often allows for decreased doses of opioids, therefore decreasing negative or adverse effects.
There are also medications (such as omeprazole and similar medicines) that make it easier for cannabinoids to reach the intestine and be absorbed, by reducing the proportion of cannabinoids that will be destroyed by stomach hydrochloric acid. These medications are collaborators of cannabinoid-based treatments.
In general terms, unless expressly indicated by the risk of immediate toxicity of medication, medications already taken by the patient will be reduced as the results are achieved. In the case that adverse effects occur, medications are not abruptly suspended due to the risk of some effects of abrupt discontinuation, which will depend on the medication in question, but, for example, could be: opioid or anxiolytic withdrawal syndrome, rebound of symptoms in the case of antidepressants, increased blood pressure or disabling pain due to lack of analgesics.
Let’s use antihypertensives as a practical example of a medication that can benefit from the introduction of CBD. Cannabidiol (CBD) has a vasodilator effect which has been verified in that is verified in many patients. To avoid discomfort and risk of excessive decrease in blood pressure in the medicated hypertensive patient, very low doses of CBD can be introduced, and the effect on blood pressure will be evaluated. Depending on the magnitude of the decrease in blood pressure levels, the doses of the antihypertensive medication will be reduced to keep the values within normal ranges. In many cases, conventional vasodilators can be suspended, and CBD can be used as the main course of treatment.
Although treatments with cannabis and cannabinoid-based products can bring great benefits to patients by reducing the polypharmacy with which they are frequently treated, the use of these new treatments should not be banalized. Always consult with your doctor when starting a new cannabis-based medication, so that the right dose can be prescribed, and interactions with other medications can be evaluated.