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The right strain & dose, with Dr. Dustin Sulak

The right strain & dose, with Dr. Dustin Sulak

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“Start low and go slow,” the widespread refrain for finding the right dose of cannabis, is actually only half the phrase, Dr. Dustin Sulak explains on The Cannabis Enigma podcast. “But [people] often leave off the rest of the sentence — it’s start low, go slow, and don’t be afraid to go all the way.”

Dr. Dustin Sulak
Dr. Dustin Sulak

Dr. Sulak, a practicing physician and renowned cannabis educator, gives his recommendations for how to choose a cannabis strain, why we need to get rid of the terms indica and sativa once and for all, and how the way you take your cannabis can have a significant impact on its effects.

“When we consume both THC and CBD and it gets into our stomach, mixed with some fat-containing food, that can enhance its absorption by up to four or five times.” Dr. Sulak says. “You might get something much stronger than you bargained for, depending on how close to a meal you had it.”

Host Michael Schaeffer Omer-Man and Dr. Sulak also discuss how the opioid epidemic created a perfect storm for medical cannabis to go mainstream, and the sometimes different needs of patient groups — men and women, young and old, etc.

In the second part of the episode, Americans for Safe Access Director Debbie Churgai explores the landmark UN vote to reschedule cannabis in a key international treaty this week.

The Cannabis Enigma podcast is a co-production of The Cannigma and Americans for Safe Access. Edited, mixed, and produced by Michael Schaeffer Omer-Man, with production assistance from Randy White. Music by Desca. 

Full transcript:

Michael Schaeffer Omer-Man: Dr. Dustin Sulak, thank you so much for joining us.

Dr. Dustin Sulak: My pleasure to be here, Mike.

Michael: So I am excited for this interview because I feel like you’re one of the medical Cannabis experts out there who’s also a clinician and therefore can speak in more practical ways and from practical experience in a way that a lot of the scientists that we have on here who are researchers, which isn’t to say that they don’t understand things at a great level, but they’re not necessarily seeing patients and you see all sides of this equation, so on that note, I wanted to start with a question about one of the issues that I find people have a lot of trouble with when it comes to medical Cannabis, and I know that it’s one that you deal with on a daily basis, which is dosing. We hear this general approach of, start low and go slow, but how do you approach this question with your patients, is there sort of a general titration sort of build-up approach that everybody takes, or are there different places that you start with different people? 

Dr. Sulak: Yeah, great question. Dosing Cannabis is really the key to success, and it’s not straightforward like it might be with other medications where a doctor can actually tell you, here’s how much to take, I think with Cannabis, the best thing that we could hear from our doctor or caregiver or healthcare provider would be, here’s a method to find out what’s the optimal dose for you, and so there’s usually a starting dose, there’s usually a titration, and that word means an amount to increase by the dose, so you would increase the dose by a certain amount, and then a frequency for titration, how often to increase that dose and what to look for, and so that’s… When I’m working with patients, everyone pretty much leaves with an individualized treatment plan, but this doesn’t mean that everybody needs someone with my experience level to get it right. That’s totally not necessary. So one of the things that we did with Healer.com, which is my free education website, was just try to make this accessible, so someone could figure this out on their own, we can start where you started, Mike, which is, start low, go slow.

This is a common phrase that people are using in Cannabis, but they often leave off the rest of the sentence, which you did also, it’s start low, go slow and don’t be afraid to go all the way. And I didn’t come up with that, that, I actually learned from one of my geriatrics mentors when I was in residency. But it’s absolutely true, because Cannabis has this incredibly broad dosing range, someone like my size and adult might respond to two milligrams a day and someone might respond to 2000 milligrams a day, and within that range, it’s safe and effective, and everyone could have an optimal dose. Now, those are outliers, I’d say probably most of my patients are using somewhere between five and 50 total milligrams of cannabinoids per day, but some people really need a lot less and some people need a lot more. When I’m designing a treatment plan to help someone figure out their optimal dosage, I’m really tying this to concrete goals, so I’m figuring out, “What are we trying to accomplish here?” If they’re not sleeping well, that’s where I start, but people usually have other things that you wouldn’t necessarily know unless you dug in.

I saw someone recently who’s top priority was to be able to play with their grandkids and that’s amazing, right? So why weren’t they able to play with their grandkids because they were in too much pain and they were getting distracted by it, so pain control is… That’s very common in the Cannabis world, but pain control without impairment, so for this person who is in their later 60s, it would be something where I’d be leaning more on the CBD than the THC, even though I would certainly include both, I would be starting low because I want them to be able to use this during the day, so I’d be a little more conservative, and so I think the starting dosage I recommended was 5 milligrams of CBD and one of THC. And I explain to the patient, you’re probably not gonna feel anything, this might not touch your pain, but then every few days, we’re gonna increase by another five of CBD and another one of THC, and keep working up to a maximum dose of 50 and 10. And if you don’t get the results you’re looking for, or if you’re feeling impaired or having any other side effects before you get there, just call the office and we’ll change out the ratio, so that’s usually how I go about this and just to give people another real simple example of a methodology, if somebody’s not sleeping well, especially if it’s sleeping maintenance, so that they can get to sleep okay, but they’re having trouble staying asleep, I’ll start with the THC dominant product.

I rarely use CBD before bed, and hopefully the product could be made from varieties of Cannabis that are known to be sedating, but if not, that’s okay, and we’ll start with two milligrams taken an hour before bedtime or taken at bed time, depending on where their kinda trouble lies if I feel like they need more help winding down at the end of the day, we’ll push it back to an hour or two before bedtime, start at 2 milligrams every other night, increase by one milligram, go up to a maximum dose of whatever, fill in the line… Fill in the blank, but I’m usually stopping people by around 15 or 20 milligrams if they need that much to sleep, usually I’ll do something adjunctive to the THC to help it work better, so that’s my general dosing approach.

Michael: And you mentioned strains that are known to be more sedative, there’s kind of a complicated place that the Cannabis market has reached, because so much of what we have today in the medical sphere actually comes from the legacy market, the black market, the days of prohibition, where we have all these strain names and the nomenclature like Indica and Sativa that don’t necessarily tell you anything. How do you approach the question of strains and what do you tell people to look for in the Cannabis or the Cannabis products that they’re getting? 

Dr. Sulak: Yeah, it’s still a big challenge. I really encourage people to take the terms Indica, Sativa, and hybrid and throw them out unless there’s really nothing better to work from. Maine is an interesting place where I practice because we have an incredibly diverse marketplace, there’s literally thousands, 3-4,000 Cannabis producers in the state, and we have very little population like two and a half… Three million people here, so we have so much variety out there, and I could never keep track of it, it doesn’t matter if I could, because the blueberry that somebody gets from one grower could be vastly different than the blueberry from another grower. So I personally think the cash register speaks the loudest. I tell people to go to their shop and ask them what sells best for people with anxiety, what sells best for people with insomnia, in other words, what do people keep coming back and purchasing again and again, and get those answers, get the top three, buy a small quantity of each of them, try ’em yourself and figure out what you like, and then if there’s something that you really like, don’t just remember the name because the names… I mean, things, the labels change, the names change.

Take a good look at it, really smell it, to get an idea of its aroma, I think people can do a great job shopping for Cannabis varieties by using their nose more so than their minds and reading the names on the containers. And so that’s some of the advice I get, I know it’s really not sufficient, but that’s kind of the best we have to work with right now. I will say to the listeners though, that this is a real subject here, it can be hard to believe that there might be 20 different varieties of Cannabis, all with the same THC and CBD content, and each one of them has a slightly different therapeutic effect. And for one person, they might just really respond great to one of those 20 varieties and not the other. That really happens. It’s hard to believe we don’t need this kind of strain specificity to get great results, but sometimes it makes a really big difference for people.

Michael: How far away do you think we are from a place where you can actually give somebody the name of something or specifications of terpenes and minor cannabinoids that would provide that sort of standardized consistency? 

Dr. Sulak: I believe we are so far from it. I mean, I don’t know if we’ll ever get there. Cannabis has such mystery behind it, I think if we’re looking at 8 cannabinoids and 20 terpenes, this is the tiny tip of the iceberg, and I honestly don’t know what’s below the water, and maybe there’s flavonoids and other classes of compounds that we should be looking at but it’s just so complex. I’ve seen varieties that have very similar terpene and cannabinoid profiles that are quite different based on my patient reports. So I think we all get excited to solve this mystery and to understand this medicine. And I do think that terpenes are a great lead, they can tell us a lot and we can learn about them, but I really caution people to think they… From thinking they have all the information they need to kind of classify and categorize these strains, because there’s a lot more going on there that we don’t understand.

Michael: Along the same vein of figuring out the right way and type of Cannabis and Cannabis product, delivery methods can make a big difference to just focus on smoking or inhalation versus edibles here, and then throw tinctures into the mix also. They take a very different pathway before the THC and other compounds get into your blood stream when it goes through the liver or different metabolites are created, is it just a matter of taste and experience, or are there different delivery methods that are actually better suited for treating different conditions? 

Dr. Sulak: Yeah, so a lot of my patients are using multiple delivery methods, and I think that that’s useful, this kind of concept of dose layering happens in medicine, usually with different drugs, but we really think about it when it comes to Cannabis using the same medicine, but in a variety of routes of administration, so inhalation has the most rapid onset, It’ll kick in in a few minutes, but it also has the shortest duration. And you can achieve very high blood levels with inhalation, which can be good for some conditions, they don’t last very long, but also because of those high blood levels, we consider inhaled Cannabis to have a relatively narrow therapeutic window, which means if there’s a certain dose that gives you relief and then there’s a higher dose that causes side effects that you don’t enjoy, how much space is there between those two doses, and for a lot of people, there’s no space when it comes to inhalation, they’re either dialed in or one toke over the line, so to speak. And that’s it.

So when we start dosing orally, because we can be a lot more precise with the dosage, the therapeutic window broadens, or at least it feels like it’s much broader because maybe four milligrams is the perfect dose for someone to be able to control their pain and function at work, but on the weekend, they prefer six milligrams because it’s okay to be a little bit stony and they get even better pain relief and it helps with their mood, and they can really dial that in and get a precise dose.

Now, there’s a couple of confounders when it comes to oral dosing, one is the presence of food that contains fats in the gut, so when we consume both THC and CBD and it gets into our stomach, mixed with some fat-containing food, that can enhance its absorption by up to four or five times, you might get something much stronger than you bargained for, depending on how close to a meal you had it, so that… Some consistency there can be important. The tinctures, I really like. No, In Cannabis, we call anything that’s a liquid, tincture, and that’s not a totally accurate term, but I’m fine using it. Tinctures are traditionally alcohol-based extracts of herbs, and very few people use alcohol preparations of Cannabis, even though it’s a fine solvent, it works very well for Cannabis, it just kind of burns the mouth and people don’t enjoy it as much.

So most of what’s called a tincture is actually an infused oil and that’s fine, but the tinctures are nice because you can be very precise with dosing, a lot of them allow you to go up in zero… In half or one milligram increments, and then you can hold them in your mouth for a while and get some oral mucosal absorption, so some of it might get into the bloodstream through the mouth and the throat, you can get a little bit more rapid onset and then you’ll end up swallowing the rest and have it go through the same pathway that like a capsule or an edible might go through, but I like that, I prefer that because a lot of people that use Cannabis have problems with their digestive track or have anxiety or pain that kind of shuts down their rest and digest, nervous system, and they’re more in the fight or flight state most days, so they can have kind of erratic GI function and erratic absorption and onset. So with most of my patients, I’m using multiple delivery methods, and I think just coming back to where I started, and say a person with chronic pain goes to the pain doctor, at least up until a couple of years ago, thankfully, this is starting to change, but they would probably be prescribed a long acting pain reliever like Oxycontin, and then they’d be prescribed a short-acting pain reliever like Oxycodone to take first so-called breakthrough pain, and they’d probably be prescribed a sleep aid and to get them to sleep and maybe a muscle relaxant.

And we achieve all of this with Cannabis, right? So the long-acting formulation would be a tincture or a capsule to kinda set a baseline, but then for breakthrough symptoms or episodic symptoms, the inhaled route is by far the best because you can just change the way someone’s feeling so fast with a little inhaled Cannabis, and then, of course, Cannabis is not just a pain reliever, it’s also a muscle relaxer, but someone might find certain varieties of Cannabis to be much better for making their body feel loose and relaxed and heavy, and so they might have a certain type of Cannabis that they inhale when they’re spasming, and a totally different one that they use for sleep perhaps, so this is the beauty of the variety of Cannabis and all these delivery methods to… The one I didn’t mention is topical, for people that have localized pain or skin conditions, I see great results with topical Cannabis. So lots of options here.

Michael: Since you mentioned it, the opioid epidemic at least before the coronavirus pandemic was probably the biggest public health crisis facing the United States and other parts of the world. Did that create something of a perfect storm for Cannabis to be brought more into the mainstream as far as treating chronic pain and other conditions? And I guess my question is, let’s call you an early adopter of Cannabis medicine, cannabinoid medicine, but there’s a lot of other physicians out there who have been and are still and probably will continue to be skeptical. Do you think that Cannabis really has the potential to replace opioids, at least in their most problematic uses, where they become addictive and long-term use in a more mainstream way, and certainly with a much safer… Safety preferred.

Dr. Sulak: Yeah, great questions. So we had an interesting experience here in Maine, and the answer to your question is yes, I think in a lot of ways, it was a perfect storm for Cannabis, so Maine passed a law that set an upper limit and the amount of opioids a doctor could write for a patient to take on a daily basis, there was an upper limit that’s around 60 milligrams of Oxycodone or 100 milligrams total of Morphine, and as a law was being implemented, a lot of docs in the states started panicking knowing what to do, and we received a huge amount of referrals from people that we had never gotten referrals from previously, and so… Yeah, that was amazing. Doctors wanting to support their patients in tapering opioids, and finally recognizing that Cannabis is one strategy that can support that taper, and I think that is happening all over the country and in other countries that are having this problem.

But by the way, I think it’s important to acknowledge that many countries do not have an opioid problem like the US does, so as of… I think it was 2008, and it’s probably gotten a lot worse since then, despite having only 5% of the world’s population, the US consumed 80% of the world’s opioid supply. So this is incredible, disproportionate over-use of opioids here, and this overuse is not a drug problem, this is not people selling heroin and so forth, then the stats I’m talking about are opioids that were written by a doctor and dispensed by a pharmacist, and so this problem really came from the doctor’s office, and the reason the doctor started this incredible opioid crisis… I think… It’s multifactorial, but in my mind, the biggest reason is because they were strongly pressured to treat pain without safe tools to do so. So I think that Cannabis, if it became a tool that any doctor who’s thinking, How can I treat chronic pain, these are general practitioners, primary care and family docs and pain specialists, also neurologists, if they all had familiarity and willingness to use Cannabis as a tool, I think that this problem would not exist right now, and.

To get Cannabis into their hands now, it’s still very important because a lot of patients are just being left out, they’re not receiving their opioids anymore, but unlike all those doctors who referred to my practice that they still don’t have another good option to use. Cannabis is an incredible tool for this because I think the way I want people to think of this is not that opioids are bad and Cannabis is good, they’re both good, they just are used in appropriate ways when we experience pain, our bodies use both cannabinoids and opioids, to address that pain, and our bodies use these compounds together, so the opioids are called the endorphins and the cannabinoids that our body makes are called the endocannabinoid and our inner pharmacy will produce both of these, they act together in similar areas of the body and brain to control pain signaling, it makes a lot of sense, pharmacologically, to use these agents together, not to use the opioids alone, and what many animal studies have shown is that when you give just a little bit of THC in conjunction with an opioid like Morphine or Codeine that opioid becomes at least three times more potent, meaning you need a third of it to get the job done, and then it’s so much safer, so why would we use opioids for chronic pain in the absence of Cannabis when all the animal data and our own physiology support this combined treatment approach, that makes it just so much more sense.

Michael: And are you seeing more of that? 

Dr. Sulak: Yeah, absolutely, so we use Cannabis to help people taper off their opioids, but some of them aren’t successful with an end up staying on this combination therapy, which works very well, people that use the opioids with Cannabis are much less likely to build tolerance and go through this dose escalation, slippery slope where they’re taking more of the opioids and they’re working less, and then opioids end up actually causing more pain instead of less pain. So we’re very successful with that. We’ve been doing that for years back in 2015. We did a survey of about 540 patients that we had seen who had added Cannabis to their opioid drugs, and about 40% of them stopped opioids entirely, another 40%, significantly reduced their dose, and I think the important outcomes are that over 80% said that their quality of life and function improved since starting Cannabis, and actually that research is probably gonna be published in a peer review journal this year, finally, but that’s not unique data.

There’s been several observational studies out of Israel, out of Michigan of all over the place that basically show those same numbers that when people add Cannabis to opioids to either reduce their dose or they get off, and there’s definitely a handful of people that it just doesn’t work for, and those people can still stay in the same dose of opioids, it’s okay if you don’t reduce it. Add Cannabis to it, and you’re probably not gonna need to escalate your dose, you probably have a better quality of life, so yeah, it’s in a little overshadowed by the whole COVID pandemic, and I think it’s still a huge issue, it’s probably even bigger now with all the social isolation, I have seen some statistics that opioid overdose and hospitalization rates have been increasing, so it’s something we can’t lose sight of, it’s a problem that my profession created and I feel very responsible to fix it.

Michael: I have spoken to a lot of doctors who feel the same way, I wanted to ask you about older Cannabis patients. I can tell you that to older people in my life, who I won’t name, but they have palindromic nicknames, ask me a lot about Cannabis and whether it can be effective in treating the ailments and conditions that we generally associate with aging from insomnia to chronic pain to inflammation and just aches and pains. Do you see more people, more older patients coming in with an open mind to Cannabis treatment and is treating them different from younger patients.

Dr. Sulak: Throughout my practice, which started in 2009, we always had this big mix of age groups coming in from very young to very old, there were certainly some elders there, but a really big increase in the older adults that were coming to see us, surprisingly happened back in 2016. After we passed an adult use law in my state, and so suddenly, it was legal for all adults to use Cannabis for non-medical purposes, and somehow this changed the public’s viewpoint or level of comfort with medical Cannabis, so all of a sudden, all of these older adults were finally willing, the people that were on the fence before said, “Oh. Well, it’s legal for recreational I better… It’s okay for me to come in for medical now.” And that was the best explanation I could get.

But we saw such an influx of older adults at that time, and now, yes, we see at least two-thirds, maybe three-quarters of our initial visits are for people over the age of 60, many of them have never used Cannabis before, or it’s been decades since they’d use it, and to answer your question, yes, Cannabis is an incredible treatment for age… Aging-related conditions, and it’s much safer than the standard therapies that are typically used. There’s a list of drugs called the beers list of potentially inappropriate medications to use in older adults. And if you look at that list and compare it with lists from other studies of classes of medications that Cannabis is likely to replace, so if you ask medical Cannabis users what drugs have you replaced, they’ll tend to say that it’s the opioids, benzodiazepines, the skeletal muscle relaxants, the anti-depressants, those are highest in the list and then usually after that come the nonsteroidal anti-inflammatory drugs, which are Advil and Ibuprofen, Aspirin, those types, and the non-traditional analgesics, so the pain relievers that are really other drugs that are being used to relief pain like Gabapentin, which is a seizure drug, and so forth, and these are categories, and then people often report using Cannabis as a substitute for antipsychotic drugs, especially when they’re used off-label to treat sleep.

And so if you look at all those lists, these are the drugs that are known to increase morbidity and mortality in older adults, meaning risk of death or risk of serious side effects from using these drugs is we know that it goes up, but it’s another situation where if doctors don’t have a good alternative, they’re still gonna use the more dangerous drug. So we’re very happy. Again, I think my profession has a responsibility to take better care of elders, it’s really disheartening to see what’s going on in publicly funded nursing facilities and assisted living facilities, we traditionally in our culture have just been so averse to facing aging and disability and death that we tend to shut our elders out of our lives and kind of put them in homes and don’t have to talk to them or go see them or deal with them, and it’s just… It’s awful, they have so much to offer us and we have so much to offer them.

So I’m really celebrating the chance to provide Cannabis to these patients and they need reassurance, they’re worried about getting high, they are worried about being impaired and falling, and they’re worried about getting it right, they can’t walk into a dispensary, they get a certificate from their doctor who knows nothing about Cannabis, and they say, Just go ask the person in the dispensary what to take, and then the person at the dispensary says, “I’m not sure. You better call Dr. Sulak.” We get that sometimes because they don’t wanna go figure it out, they want a methodical step-by-step plan to ensure they’re gonna get good results and thankfully, that’s what we can provide.

Michael: We just published an article on the [29:02] ____ this week, one that fascinated me, and I’ve heard the same thing from a lot of other people about biological sex differences and the way that Cannabis can affect people or how it’s experienced, and there’s all sorts of different explanations, it’s all theories still at this point, but it could be the way… The different hormone levels or that the endocannabinoid system is actually sexually dimorphic… I hope I said that, right? And the result being that, for instance, Cannabis can be a less effective pain reliever for women and various other differences that can… Based on biological sex, is this something that you’ve experienced or that you take into consideration.

Dr. Sulak: Yes. These are trends, but there’s all we’ve got in Cannabis medicine are trends, so you ask me, do older adults get dosed differently than middle age or younger adults or even children, and I would say there’s probably a trend that older adults are actually using more, but there’s gonna be lots of exceptions to that trend, and so why might older adults need higher doses of Cannabis? Maybe it is because… And we see this in animal studies, and to some extent, there’s some human data supporting this, that as we age, the endocannabinoid system kind of ages and becomes less sensitive and less active, and we see similar trends with the male-female split, so it might be that women are less responsive and need a higher dose, it also might be that their requirements change throughout the menstrual cycle because levels of estrogen are different and estrogen seems to impact cannabinoid sensitivity, but all of these are things to observe, but they don’t really impact my recommendations that I give to patients, because it’s kind of the same for body weight too, theoretically, a bigger person might need more Cannabis, but we never go by that with our recommendations, because we see really big people that need tiny doses and little tiny people that need big doses.

So these are trends, but they don’t impact the clinical practice that much, in my opinion, I will say that if I had to pick a certain demographic that was more likely to need a very high dose of THC for pain, I would… Probably it be older women, but again, lots of exceptions to that rule.

Michael: I’m trying to decide where to go next. So in my very skewed sample of older people experimenting with Cannabis for therapeutic reasons, the number one out of two people reason that they’ve wanted to try it was with sleep, insomnia. I know it’s an issue that a lot of older people deal with, but people of all ages as well, and Cannabis is also something that a lot of people use to help with sleep, however, I’ve heard from several doctors and researchers that it can reduce or suppress REM sleep, which in theory would make your sleep less lower quality. So I wanted to actually throw a much more holistic question at you, which is the importance of sleep and treating other conditions, but also whether Cannabis… Whether Cannabis is… How effective it is for treating insomnia and sleep and how people might go about it? 

Dr. Sulak: Yeah. So you’re right on with the line of questioning here, because sleep is essential, anyone that wants to heal or change daytime symptoms can usually do so better if they’re getting restorative sleep at night, and I could essentially take a very healthy person and disturb their sleep for a month straight, and they’re gonna start feeling like they have fibromyalgia or a lot of the other conditions that I end up treating, and so very often, I’d say maybe 25% of the time when I see a patient for an initial visit and they’re not sleeping well, I give them a two-stage plan that’s… Step one is, Let’s get you sleeping good, and then step two is Let’s start treating your daytime symptoms. And so probably about 25% of the time, they come back for their first follow-up. Saying, I just did step one, I’m sleeping better. My day-time symptoms are better already, I didn’t even feel like I needed to follow up on your step two, so is that powerful, getting deep restorative sleep is really essential to not just improving the way we feel, but to staying healthy. Disturbed sleep is a major risk factor for cardiovascular disease, stroke, obesity, diabetes, arthritis, and so this is a kind of a public health pursuit as well, if you’re just having poor sleep, but you still feel like you’re healthy, then it’s urgent for you to correct the sleep disturbance before you become sick.

Now, what you mentioned is something I frequently hear, including from sleep experts, who you would expect to have a really good handle on the data. Oh Cannabis or THC, it might make you sleep, but it’s going to disturb the architecture of your sleep and make it so you’re not getting good quality sleep. And trust me, I am familiar with 100% of the Polysomnography studies that have been done on humans who use Cannabis. So Polysomnography would be a sleep study where they’re measuring multiple factors including what’s the brain wave state, and is somebody getting the necessary stages of sleep to help them both process their memories and store the memories and let the body heal, and there is very little data to support this idea that Cannabis interferes with sleep architecture in the range of dosing that most people would use, and I think the best study to support this showed that they dosed Cannabis in a way that actually had a slight negative impact on the cognitive tests performed the next morning, so that means somebody was groggy, or stoned or hung over from the dose of Cannabis that they had received, and even at that threshold, there was no disturbance of sleep architecture, there was slightly…

So there’s stage three sleep and stage four sleep are very similar, nowadays, most people just kinda lump them into one, and there was this very slight decrease in stage three sleep and a little increase in stage four sleep, whatever that was considered not clinically irrelevant, but… So essentially what I’m saying is that if you titrate the dose of THC taken before bed to help you sleep as well as you can, and you don’t wake up feeling stoned or groggy, then it’s extremely unlikely that you’re interfering with the quality of sleep and in my opinion, it’s extremely likely that you’re getting a better night’s rest, and that’s different than the benzodiazepines like Valium and some of the other prescription sleep aids, which do knock you out, but they also do interfere with the both dreaming state and the slow wave sleep.

So Cannabis is not what we call a hypnotic, it does not produce sleep, you’re not gonna give it to someone and make them fall asleep, but what it does is it mitigates all the things that are interfering with sleep, so it’s helping with the anxiety, it’s helping with the pain, it makes the body feel more comfortable and it produces something called catalepsy, which is like this ability to stay still, which is very useful for sleep, helps people with restless legs, and then psychologically, it allows people to wonder in their minds, not ruminate and go on these repetitive cycles again and again and again, reprocessing the same regrets from the past or anxieties about the future, and they can just feel like themselves and wander off into the present moment, which can take them into dreamland.

So I do not think that THC is a problem for sleep, I think it’s a wonderful help for sleep, it goes really well with other sleeping aids, wether natural, herbal or pharmaceutical. It can be used in conjunction with them safely. I’ve been warning people, especially older adults for the last 11 years, when I’m titrating their nighttime dose of THC to watch out for fall risks, I don’t want anyone to fall on the way to the bathroom, so we talk about corners of rugs and furniture and bathroom night light and stuff like that, but I have never had a fall related to Cannabis after all these times, treating people in this way. And if their titration increment is small then the worst thing that’s gonna happen is they’ll feel a little groggy the next morning, you know that that’s their upper limit and it’s time to back off by one drop or one milligram, and then they hit their sweet spot, and if it’s not powerful enough to produce really good sleep, then we start layering in some other treatments to use with the THC.

And so as I described it before, I start at two milligrams. It’s not enough for most people. Once in a while, it is enough, but that’s where I start and then we don’t increase the dose every night because there’s just gonna be this natural variability for people to have some nights of better sleep and some nights of worse sleep, and I just don’t wanna be too aggressive with the dosage increases, so I usually have people bump it up by a milligram every two to three nights so that they can really look at a trend of how a certain dose is affecting them. And I don’t use CBD for sleep, not very often, and the reason for that is because CBD has really mixed results, some people say it helps them sleep, I think those are probably people that are more anxious, some people say it interferes with their sleep, it makes them feel awake and mentally active and alert, and then some people say it doesn’t do anything to their sleep. But one study that did look at CBD before sleep found that as a little as 5 milligrams, and this was taken in conjunction with THC, 5 milligrams of CBD was enough to disturb sleep architecture, and I think it was 15 milligrams started producing more nighttime awakenings. And it’s probably very different. I really do believe that some people will get better sleep with CBD and some people will not, but in my mind, why mess around with that if there’s such a variety of responses when THC seems to work so well.

Michael: So that actually dovetails really nicely with what I wanted to ask next, which is that we had Dr. Ethan Russo on the podcast a few weeks ago, and one of the things that he said that really resonated with me and that I also heard from other people who listen to the episode, and I’m quoting now, is “That there’s nothing that CBD does that won’t be enhanced by having at least a tiny amount of THC presence as well.” And that sort of got my mind thinking about all sorts of things, but what it really brings up for me is what that says, not necessarily about, but for the CBD craze, for lack of a better term, and all of the hemp-based CBD products out there, and whether there’s people who just aren’t getting the benefits that they could be getting.

Dr. Sulak: Oh yeah, so that’s the new trend in our older adults, is that they tried CBD and it didn’t work, so they told either their doctor or their family member about that, and they said, “We need to go talk to Dr. Sulak or colleagues,” because hemp-based CBD does help a lot of people, especially when it’s a product that actually is accurately labeled, that contains what it says it contains. I mean, CBD is a great medicine. I’m really thankful for the CBD craze and that it’s out there, has a lot to offer people, but it’s not very strong, and to get great results, a lot of people need to use more than they might be able to afford, and what’s the point? If you live in a legal Cannabis state, why lean so heavily on CBD and ignore this powerful THC gift. So yeah, I’m right there with you. We are usually using CBD more as an adjunct to THC than the other way around. And it’s interesting, a lot of the older adults and others as well, they don’t wanna get stoned, right? So that’s why their initial visit, their primary request is to really do this in a way that’s non-impairing.

And we say, “Fine, we get it, you don’t wanna be stoned while you’re trying to work or take care of your family or do anything, that’s fine, you don’t have to be stoned.” We’ll make a plan that is more CBD dominant, but rarely are we using these 30 to one ratios. Once in a while we will, but it’s usually probably more like what Ethan was thinking about, like five parts CBD, and one part THC, or maybe 10 in one and something in that range is gonna be a lot more cost effective than a 30 to one ratio for a lot of people. But then they come back and they’re doing fine, and kind of the way that I can suggest that they begin to explore the psychoactive effects of Cannabis is that night time dose of THC that you’re taking one night per week, pick a night where you just really wanna relax and lay back and have a good time, you’re not going out anywhere, try taking that night time dose of THC around supper time, and let’s see what happens.

And I prepare them to have a positive internal mindset about seeing what it feels like to experience those consciousness-altering aspects of THC, and that’s because, Mike, in my opinion, the effect that THC has on our consciousness is still probably the most important therapeutic aspect of Cannabis and I know it’s hard for people to understand, when it’s got all these great anti-inflammatory and muscle relax and anti-pain and neuroprotective properties and everything else, but I’ll tell you, it can help with all these different symptoms, it can help improve people’s quality of life, but when I see someone that’s healed, someone that’s really changed their health, it’s because they’ve had a shift in their patterns of thoughts and their patterns of behavior, their perceptions of the world, and therefore a shift in their physiology.

That’s usually how it works and the way that Cannabis can help people disengage from their current patterns and get this new perspective on themselves and feel a little euphoric can suddenly have this experience of, “Wow, I’m really sick and miserable and suffering, yet at the same time I’m feeling happy and carefree and in love with my situation.” Cannabis can do all of that for people, bring these paradoxical experiences and opposites can come together and people find creative solutions to their problems, so I’m a strong proponent of Cannabis users actually experiencing the THC in a way that where it can touch their consciousness. And when I recommend this to people, they usually come back and say, “Oh, that was it. That was like a glass of wine or two, but better,” I think a lot of people are expecting some profound psychedelic experience or something like that from a handful of milligrams of THC or a couple of puffs, but that… This is something that I’m recommending a lot, and I think that the whole CBD craze has made THC, especially the psychoactive aspects of THC, seem undesirable, and I’d love for the listeners to realize that they are not undesirable, they’re a hugely therapeutic effect.

Michael: I think the CBD has also, maybe not for the same people, but also helped break down some of the stigma around Cannabis and things that come from the Cannabis plant, more generally.

Dr. Sulak: Absolutely.

Michael: So my final question here… I have plenty more questions, but we’re running out of time, has to do with tolerance and those psychoactive effects, the euphoria, the high, let’s call it. I wanted to ask, people can develop a tolerance, at least to that, to Cannabis, we talked about how it’s not the same as with opioids when it comes to treating pain, so I’m wondering… And I asked Dr. Russo about this as well. If you develop a tolerance to the high, does that also have the same effect that you need more of it for other therapeutic targets that you might be using it for? And just as a quick follow-up, I saw on your website on Healer.com that you have a video about sensitization, which I imagine is sort of reversing that tolerance.

Dr. Sulak: Yeah.

Michael: Can you talk about sort of what the role that plays with the people who are using it, particularly over a long period of time.

Dr. Sulak: Sure. So tolerance to Cannabis, especially THC, builds when our cannabinoid receptors, which are like these little antenna on the surface of ourselves, when they become over-stimulated, then the cells likely to pull that receptor inside and then it’s no longer available for stimulation. And the THC doesn’t have an effect on that cell like it used to. Interestingly, the same thing would happen if we build tolerance to THC, then we’re also undermining the effects of our endocannabinoid system, we’re making it so that the endocannabinoids no longer have access to that receptor as well. Now it’s been shown within the brain, as well as within the rest of the body, that different parts of the brain and different tissues will develop tolerance to Cannabis at different rates, and so you could have one part of the brain that’s become tolerant and another part that is still very sensitive.

And I think that this is most obvious in people that are brand new to Cannabis, at a certain dose of THC, they might feel like while they’re getting good therapeutic results, but they’re also getting dizzy, clumsy, forgetful and so forth, so we’ve got different areas of the brain at work here, pain signaling areas, and then motor function areas, and it’s been shown that the motor systems will develop tolerance more quickly, so you talk to that same person a week later and they’re saying, “Yeah, the same dose is still working for my pain and it’s no longer making me feel clumsy,” and whatever those other side effects were.

So in general, and this has been described as far back as the 1970s, there seems to be this ability for THC to widen its own therapeutic window, so before we were talking about that distance between the therapeutic dose and the dose that causes adverse effects, it can be really narrow when someone’s brand new to Cannabis. Give them a week or two, and now they’ve got more room there because they’ve built tolerance to some of the negative effects while they have not built tolerance to the beneficial effects. So that’s just another reason for start low and go slow, and don’t be afraid to go all the way. If you start low and go fast, you might hit that upper limit of the therapeutic window before someone’s had a chance to let it get wider and it will get wider.

So yeah, if somebody’s built tolerance to certain aspects of Cannabis, be it the psychoactive or others, it does not mean that they’ve lost therapeutic efficacy, but sometimes they kinda globally build tolerance and they do lose therapeutic efficacy, and we see this a lot. It’s just, a lot of people wouldn’t expect that if they’ve used Cannabis and it used to work for them and it stopped working, and then they increased the dose and it worked better again for a little while, and then it stopped working again, and then they increased the dose and kept repeating that, a lot of people would not expect to hear, “Well, if you want it to work better, if you want a stronger effect from Cannabis, just reduce your dose.” It seems so counter-intuitive that less could be more, but with Cannabis, it absolutely is.

And so one of the things I was seeing from early on in my practice, when the vast majority of my patients were already using Cannabis, many of them had been recreational users that now needed it for a medical purpose, and they had built enough tolerance to Cannabis that they weren’t getting good results and wondering what to do. And so over a few years, we developed this program, which is now for free on healer.com, as you mentioned, the sensitization protocol, which basically walks people through a 48-hour Cannabis fast. It’s interesting, and another really wonderful thing about this medicine is that that’s all it typically takes for people to reverse tolerance is just stop using it for two days, we have brain MRI imaging, at least from male subjects that confirms that, that after about 48 hours, the brain levels of the CB1 receptors go back up to their baseline function.

And then after those 48 hours, we like people to go through a really careful process of starting Cannabis again at a lower dose, and titrating it very carefully until they find their optimal dose, and that’s the beautiful thing, Mike, because when someone is at their unique optimal dose, they do not build tolerance, they could use Cannabis for years or decades without losing any of the therapeutic effects. And so I think that it’s just so easy to get good results with Cannabis when you kinda have this understanding of this education, and so thanks for bringing this to your listeners. I think that’s really important.

Michael: Dr. Sulak, thank you so much for taking the time. This has been a real pleasure speaking to you.

Dr. Sulak: You’re welcome, Mike, I appreciate it. You ask great questions, and this is important information to get out there.

Thanks for your feedback!

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