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Friday, January 1, 2016

What to Look For at Medical Marijuana Dispensaries

If you're not a pot user but you are interested in marijuana for medical applications, you probably don't know what to expect at medical marijuana dispensaries. You may be surprised to learn that one strain of pot doesn't work for everything. In fact, there may be different kinds of marijuana that either hurt or help your condition. Here's a quick guide to what to expect from a legal marijuana dispensary, by health condition.

When I first started writing about herbal medicine over 20 years ago, my publishers strictly admonished me that I must not even use the word "marijuana." Frankly, I was never into pot, and I'm hardly a recreational marijuana expert. What I know about medical marijuana, I know from interacting with vendors and users.

I do, however, pay close attention to medicinal herbs. Marijuana isn't a cure-all, but it can be useful, sometimes extremely useful. Now marijuana is a legal alternative to medication (for at least some conditions) in a majority of states in the USA. That doesn't mean, however, that every strain of weed is useful for every health condition. Here's a quick guide to what works for what. Let's start with the question, "What is medicinal marijuana?"

The US government provides a handy field guide to pot, Marihuana: Its Identification. Published in 1938 by the US Bureau of Narcotics, it’s more than a little dated, but its basic description of the art and science of marijuana identification is still correct.

Marijuana plants typically have leaves that grow in groups of seven. These identically shaped, serrated, symmetrical leaves occur in a pattern. If you were to imagine the leaf imposed on a clock face, there would be a long leaf at 12 o’clock, two smaller but identical leaves at 11 and 1, two more at 9 and 3, and two stunted leaves at 5 and 7.

“To the experienced observer the appearance of the hemp plant marihauana (Cannabis sativa) is as distinctive as is the appearance of corn or wheat to the farmer,” the US government manual assures us. What the US government manual fails to explain is that the leaves aren’t where the action is. Marijuana’s recreational and medicinal effects derive from its flower buds. The flower buds are the principal source of the 700 or so medicinally active chemical compounds made by the plant, although different strains of the plants make different amounts of the active chemicals. And more specifically, most of the medically important chemical compounds are made by the hairs on the flower buds, known as trichomes.

From the Plant’s Point of View, Medical Marijuana Is All About Sex

A plant’s flowers, of course, are its reproductive organs. The female sex organ is the pistil, which makes the seed. The male sex organ is the stamen, which makes the pollen which fertilizes the ovum in the pistil.

Sexual reproduction in marijuana plants does not require the birds or the bees, since marijuana pollen is spread by the wind. Sexual reproduction in sativa and indica plants does depend on the seasons, since these two most common species of marijuana are “short day” plants. They do not bloom until days grow shorter, usually in October in the Northern Hemisphere and in April south of the equator. There is a third species of marijuana, Cannabis ruderalis, that blooms when it reaches a certain age, regardless of how much sunlight it gets.

Many plants are hermaphroditic, containing both stamens and pistils in the flowers of the same plant. Marijuana, in contrast, exists as male and female plants, male flowers producing pollen and female flowers producing seeds. Because the tiny, spike-like trichomes that contain the chemicals that provide a high or a medicinal effect exist to protect the seed, they are more abundant on female plants. Every marijuana plant has trichomes. Even the aforementioned US government manual says “No plant material which fails to show them can be marijuana.” Also, without trichomes, marijuana isn’t for all intents and purposes marijuana. You can’t get high from a marijuana smoothie made with marijuana leaves. There isn’t any special medicinal value to adding marijuana greens to your salads.

That’s because even when you have the trichomes (and there are small numbers of trichomes on marijuana leaves and stems), you don’t get the psychoactive and medicinally active chemicals in high concentration until the trichomes have been dried, and some of the active compounds like THC have to be released by heat. That’s where smoking and vaping come in. However, there’s something else to consider first.

Like Crossing a Chihuahua and a Great Dane

Marijuana doesn’t just come in different species, sativa associated with getting high and indica associated with medicinal effects. It also comes in different varieties, usually known as strains.
The idea of different strains is not especially hard to understand. Dogs, for instance, also come in different “strains,” better known as breeds. Both a Chihuahua and a Great Dane are the same species of animal, Canis familiaris. With some anatomical challenges, a Chihuahua and a Great Dane could mate and have puppies. The first litter of puppies might look something like a half-Chihuahua half-Great Dane hybrid. If those puppies found other mixed breed Chihuahua-Great Dane puppies with whom to reproduce, however, then their children would probably display a variety of traits inherited from their grandparents.

Similarly, when marijuana growers cross a sativa that produces unusually high amounts of the psychoactive chemical THC with an indica (or another sativa) that produces unusually high amounts of the mostly-medicinal chemical CBD, the offspring in the first generation tend produce both THC and CBD, but  not in unusually high amounts. By crossing the offspring, however, growers eventually create strains that are even higher in THC, or CBD, or both, than the strains with which they started. And because different disease conditions respond to different chemicals in different ways, different strains of marijuana are needed to get the optimum healing effect.
Alzheimer’s. Different strains are used for different purposes. When the primary concern is calming and sedation, high-THC strains (such as Bubba Kush, Grand Daddy Purple, Hash Plant, and Purple Urkle) give better results. When the primary concern is preventing progression of the disease and maintaining existing skills, high-CBD strains (such as Cannatonic and Harlequin) are preferred.
·      For a “couchlock” effect, strains with high content of the chemical myrcene are preferred. Myrcene is found every strain of cannabis, but it is especially abundant in the Dutch marijuana plant Bedrocan.

Anxiety. Both CBD and THC are useful in relieving symptoms of anxiety, but their optimal dosages differ. THC is most effective in doses of 1 to 3 mg, while CBD is more effective in doses of 3 to 10 mg. The problem is, most strains of marijuana contain more THC than CBD, so getting enough CBD to quell anxiety involves getting enough THC to cause a stoner effect.  Just “smoking a lot of pot” can actually make anxiety worse.

The solution is to use one strain for its THC content. Any purple strain in “microdoses” would work, as would Bubba Kush, Diesel, or Haze.  Marijuana that has a lavender odor, which indicates that it contains linalool, the same calming chemical found in lavender, may also be helpful, even if the strain is not usually used for anxiety. High-linalool varieties of marijuana include Then, especially for panic disorders and social phobias, a high-CBD variety such as Cannatonic can be helpful.
Some cultivars of marijuana contain chemicals that can cancel out the calming effects of low doses of THC and higher doses of CBD. These are plants that contain the chemical THCV (Malawi Gold and Willie Nelson). If it’s one of those rare strains that doesn’t cause the munchies, then it probably isn’t good for anxiety.

Appetite Problems. “Munchies” are a common side effect of smoking pot, and correcting loss of appetite is a popular application for medical marijuana. The thing to remember about using medical marijuana for loss of appetite, anorexia, and cachexia (weight loss in chronic disease) is that just a little THC is enough, and too much THC may reduce its effectiveness. Just 2.5 mg of THC before a meal is enough to stimulate appetite. That’s the dosage of THC found in Marinol, the synthetic form of the plant chemical. Another chemical in marijuana that stimulates appetite is beta-caryophyllene, which is also found in cloves.  Any strain of marijuana that has a natural “peppery” aroma, such as Panama Red or Super Skunk is most likely to be helpful.

Arthritis. In treating arthritis pain, there’s usually a “sweet spot” where just enough but not too much THC relieves pain and helps joint flexibility without leaving the user glued to the couch. Few people will get pain relief with less than 5 mg of THC per dose, so that’s the place to start. CBD seems to be helpful in fighting inflammation. It may relieve the underlying cause of the disease. A high-THC, stimulating variety such as Trainwreck may be the place to start, then adding Cannatonic to fight inflammation.

In theory, harvesting flowers early when they have a high content of a chemical called CBG would provide a product that has a good balance of pain relief and anti-inflammatory properties. These strains are hard to come by, however, the Dutch strain Bediol is harvested to maximize CBG content.

Asthma. Smoking marijuana doesn’t seem like an intuitive way to treat asthma. When a researcher named Donald Tashkin first ran a test of marijuana as an asthma treatment back in the early 1970’s, he used a strain that provided less than 1/5 mg of THC per dose. When doctors used cannabis in the nineteenth century to treat asthma, they typically used tincture of cannabis in equivalently small amounts. 

So where does this leave marijuana as a treatment for asthma now? More is not necessarily better.  

Especially if you are using vape or smoke, you need to minimize the dosage. Edibles act slowly. Products you take orally will never replace asthma inhalers. An edible, oil, or tincture simply cannot get the product into general circulation fast enough.

·      Vaping and smoking are the fastest way to get THC into the lungs to calm them, but they aren’t always a great idea, either. It’s important to start with a very small hit, to see how it is tolerated.

·      Organic is not necessarily better. Moldy marijuana can trigger an asthma attack on its own. It’s best to get marijuana from a dispensary that tests its products for bacterial and fungal contamination.

·      The best varieties for vaping for asthma control have a mild piney scent. This is due to pinene, which opens bronchial passages. Some trial and error may be necessary to find what works best. Sno-Cap, Super Silver Haze, and Trainwreck are a place to start.

Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder. Most treatments for attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) involve mild stimulation of the brain. Medical marijuana for ADD/ADHD works the same way. A dose of 2.5 mg of THC usually helps increase focus for about 90 minutes. More than that, and there may be a sedative effect. Either troches (“trokies,” allowed to dissolve in the mouth while held in the cheek) or tablets you hold under your tongue (sublingual ingestion) work better than edibles and oils, because the THC goes into the bloodstream directly when taken as troche or sublingual, but has to pass through the digestive tract if it is swallowed. Patients usually report best results with Neville’s Haze, Pincher Creek, or Trainwreck.

Autism. Few things are more likely to get the attention of child welfare authorities than reports of parents encouraging their autistic children to smoke pot. Vaping is likewise not a good idea. In many states, however, children whose autism is especially hard to manage are approved for medical marijuana. Edibles that have high linalool or myrcene content, however, such as those made from Bubba Kush or Grand Daddy Purple for THC plus a high-CBD variety such as ACDC or Cannatonic both relieve anxiety and protect neurons.

Cancer. Marijuana, unfortunately, does not cure cancer. It’s never enough to defeat the disease by itself. However, some strains are more likely to help stop tumor growth than others, notably the high-CBD strains such as Cannatonic. CBD-rich strains also help relieve anxiety. THC-rich strains such as Bubba Kush, Grand Daddy Purple, OG Kush, and Pincher Creek are useful for stimulating appetite, relieving pain, aiding sleep, stopping nausea and vomiting caused by chemotherapy, and fighting anxiety and depression. However, really high doses of THC, 30 mg and up for relieving nausea and chemotherapy can also trigger anxiety. Sometimes there are tradeoffs even with medical marijuana.

Chronic Fatigue Syndrome. For fighting chronic fatigue syndrome, marijuana has a paradoxical effect. THC, the chemical that makes you “high,” actually doesn’t do the most to relieve symptoms. CBD, which is better known for fighting inflammation, is more effective. Cannatonic and Harlequin are more useful. Vaping is generally more effective than smoking, but it’s important vape at a temperature high enough to release CBD. THC vaporizes at a temperature of 157°C (315°F) but CBD vaporizes at 180°C (356° F). If you don’t vape hot enough, you may get high, but you won’t feel more energized.

Diabetes. Since the best known side effect of marijuana is increased appetite for carbohydrate foods and eating extra carbs is a major no-no for diabetics, it isn’t immediately obvious how marijuana could be useful In fighting diabetes – but the value of medical marijuana for diabetes comes in preventing complications of the disease. High-THCV strains such as Malawi Gold and Willie Nelson actually reduce the urge to eat. However, don’t start using some other strain to control appetite and expect anything other than increased appetite. High-CBD strains may help protect against diabetic retinopathy, but any strain that is high in both THC and CBD will have the side effect of increasing appetite. Constance Pure Botanical Extracts, which was among the first in the world to grow CBD-rich cannabis, has an oil that may be helpful to people who already have diabetic retinopathy, but they will probably want to discuss your condition with you before they sell you the oil.

Eczema. The constant itching caused by eczema (atopic dermatitis) can have disastrous results. Children, in particular, but even adults can scratch away skin, leaving bleeding open abrasions that invite infection – and itch even worse. In treating eczema, marijuana is used in forms that aren’t used for other conditions, namely hemp oil (which is legal in more jurisdictions than other cannabis product) and high-CBD creams, applied directly to the skin. In the worst cases, smoking Canantonic, Harlequin, or Purple Urkle will quell the itch; these strains are OK to be used before bedtime.

Fibromyalgia. THC is the component of medical marijuana that seems to have the most effect on fibromyalgia. Fortunately, it’s relatively easy to get a high-THC strain. Pain relief seems to require taking a dose of THC that is at least at the threshold of psychoactivity, 4 to 5 mg, and many people get better results with 10 mg.

Glaucoma. When glaucoma became one of the first exceptions to the laws prohibiting marijuana use back in the 1970’s, the standard treatment for the condition, pilocarpine, really wasn’t especially helpful. Better pharmaceutical treatments exist now. However, marijuana is still helpful. The limitation of marijuana in lowering intraocular pressure (IOP) in glaucoma is that the THC it delivers only lowers pressure for 3 to 4 hours at a time, and constant use of marijuana causes the body to build up tolerance so that more and more marijuana is needed for the same effect on eye pressure.

The problem is that there are no known marijuana eye drops that actually work. Marijuana has to be smoked, vaped, or taken as an edible. If your intraocular pressure is otherwise controlled on a prescription medication, then a high-CBD product like Cannatonic or Constance Pure Botanical Extracts CBD Oil may help protect the optic nerve from further damage.

Hepatitis C. Different stages of the medical treatment of hepatitis C call for entirely different approaches to the use of medical marijuana in assisting remission. When the disease is not active, fighting insulin resistance (which amounts to limiting calorie and carb intake) helps keep the virus at bay. For this, a high THCV- (not THC) strain such as Malawi Gold or Willie Nelson may help. THCV may also retard or stop fibrosis of the liver. During treatment, a high-THC (not THCV) strain may prevent nausea and vomiting, when taken in a dose of up to 25 mg.  During treatment, strains such as Harlequin, OG Kush, Pincher Creek, and White Widow are preferable.

HIV and AIDS. The primary use of marijuana in treating HIV and AIDS is stimulating appetite. High-THC strains are best. Appetite stimulation may occur after a single dose of 5 mg of THC, but many people with AIDS need 12.5 to 25 mg to overcome loss of appetite if it is accompanied by nausea and vomiting. In AIDS, it is important to avoid high-CBD strains, since they may reduce appetite.

Cannabis-infused lollipops are a preferred vehicle for delivering THC in AIDS. The THC doesn’t have to be swallowed. It enters the bloodstream through the lining of the mouth. It won’t be lost if there is vomiting, and it gets into circulation 2 to 3 hours faster than through the digestive tract.  Banana Kush, Green Skunk, and OG contain the high amounts of THC needed to stimulate appetite.
Vaping and smoking are better when the problem is neuropathic pain, but when the purpose of using marijuana is pain control, a high-CBD strain is preferred to a high-THC strain. Cannatonic is the best dual-purpose strain for both pain control and appetite stimulation.

Insomnia. Researchers demonstrated that THC relieves insomnia shortly after it was discovered in 1964. It reduces the time required to fall asleep, but it also suppresses deep sleep and can produce hangover-like symptoms.  The best way to get around this problem is to choose an indica variety that is high in the aromatic chemical myrcene, such as El Niño, Himalayan Gold, Pure Kush, Skunk #1, or White Widow.

Timing the use of marijuana is important. THC is initially stimulating, but only later sedative. It takes about an hour for the chemical to induce sleepiness. If you wake up in the middle of the night, it is better to use an oral form of cannabis (oil, edible, troche, or lollipop) rather than smoking or vaping marijuana, which will be less stimulating.

Migraine. Marijuana is one several herbs (including butterbur, which is also known as Petasites, and feverfew) used to prevent migraine. However, the strains that are most helpful for preventing migraine are not the same that are most helpful for treating it. A low dose of THC (just 2.5 mg) every day can help prevent migraine headaches. High-THC strains are also helpful when symptoms are just beginning, during the prodrome that warns that a migraine headache is on its way. During the early phase of migraine, many report success with Girl Scout Cookies or Thai Lights. Once the migraine has already started, true kush and purple strains such as Grand Daddy Purple, MK Ultra, Purple Urkle, or Purple Kush,  are better for treating pain and nausea.

Multiple Sclerosis (MS). The most common use of medical marijuana in treating MS is relieving muscle tension and spasticity. MS can cause painful muscle spasms, difficulties in focusing the eyes, tremors, weakness, loss of bladder control, and speech impairment. The severity of symptoms can range from mild discomfort to complete disability. THC-dominant strains are most useful.
For MS, the general rule is that edibles and less effective than “smokeables” and sublingual or buccal products (products you allow to dissolve under your tongue or melt in your mouth). Marijuana does not eliminate pain and spasticity, except in rare cases, but it usually reduces them. Moderate doses of THC, 2.5 to 10 mg, relieve pain, while lower doses, 2.5 mg or even less, are usually helpful for neuropathy. For MS, a variety of high-THC strains of cannabis offer not just THC but also the terpenoids that relieve subtle symptoms of the disease. Useful strains include Blue Dream, Bubba Kush, OG Kush,Pincher Creek, and Trainwreck.

Neuropathy. There are a number of new pharmaceutical treatments for the stinging, tingling, burning, and numbness caused by neuropathy. Unfortunately for patients, most of them don’t work. The Center for Medicinal Cannabis Research at the University of California ran a clinical trial comparing marijuana to tricyclic antidepressants (a treatment that has been around for decades), selective serotonin reuptake inhibitors (medications in the same class as Paxil and Prozac, which have been available for about 20 years), gabapentin, and anticonvulsants. Project director Dr. Igor Grant and colleagues found that marijuana wasn’t quite as effective as the older, inexpensive tricyclic antidepressants, but that it was more effective than all of the newer, more expensive drugs.  Other studies have confirmed that medical marijuana is effective, although not perfectly so, in treating neuropathy caused by HIV and MS. A study in 2014 found that CBD-rich marijuana relieves neuropathy caused by chemotherapy.

What form of marijuana works best?

For longer-acting relief, edibles are preferable. They usually give pain relief for four to six hours.
For faster-acting relief, vaporization and smoking are preferable. Their effects start faster
No matter what form of marijuana you use in treating neuropathy, it is important to remember that more is not necessarily better. As little as 2.5 mg of THC may be enough to achieve pain relief.

Which strains of marijuana work best?

For neuropathy, both high-THC and high-CBD strains can be helpful, although for different reasons. THC is psychoactive, relieving the “pain in the brain,” the sensation of pain. CBD may have a greater effect on the physical inflammation of damaged nerves.

Pain. For back pain, bone pain, central pain, visceral pain, fibromyalgia pain, myofascial pain, neuropathic pain, osteoarthritic pain, and other types of pain, marijuana is effective therapy – provided they can be taken in the right dose. Marijuana also sometimes restores the effectiveness of opioid medication (OxyContin or Vicodin, for example) after they have been used in doses so high that their effectiveness has been lost.

For many conditions, either THC or CBD is the more active plant chemical in marijuana. In treating pain, however, a combination of both THC and CBD is best. (People who have not used marijuana before usually find it easier to deal with high-CBD strains rather than high-THC strains, because of THC’s psychoactive effects.)  It’s even better when the product contains CBG, which is a stronger pain reliever than THC, and THCV, which at least in animal studies is best at relieving intense pain. 

Dosage makes a difference. More is not usually better. Low to moderate doses of marijuana tend to give better pain relief and to cause fewer side effects. Too much THC ceases to provide additional pain relief and can trigger anxiety and racing heart.

The aromatics in the bud used for pain relief are also important. Afghan contains both THC and myrcene, which give it more pain relief and relaxation than most other varieties. Trainwreck contains more THC, which is a stimulant, so it is used to daytime pain relief.  Purple strains contain linalool, the same chemical found in lavender, and are useful in relieving both burn pain and headache pain. When pain is caused by inflammation, a higher-CBD strain such as AC/DC or Cannatonic is best.

Parkinson’s Disease. In Parkinson’s disease, marijuana is more helpful in relieving the pain of rigidity than it is for stopping repetitive motion. There has been some research with animals that suggests that high-THCV varieties, such as the previously mentioned Malawi Gold and Willie Nelson, as well as Durban Poison and Swazi Skunk, may stop progression of the disease, or at least slow it down. Smoking and sublingual (under the tongue) forms of marijuana get the best results.

PTSD (Post-Traumatic Stress Disorder). Since 2012, veterans groups have been lobbying the White House to legalize the use of cannabis for treating PTSD in the United States. There is a very long history of using cannabis for the condition. In the 1500’s, Portuguese doctor and botanist Cristobal Acosta noted that soldiers in Goa (western India) used bhang to “forget their worries and sleep without thoughts…to enjoy in their sleep a variety of dreams and delusions…or to get drunk and act like clowns.” The evidence for using cannabis to treat PTSD is still mostly case reports, but there are persuasive reports that it can stop flashbacks, panic attacks, and self-mutilation.

Which varieties of marijuana are most helpful? Right now, the evidence is that the only strains that are not helpful are those that contain the chemical pinene, which gives the product a pine wood scent, because pinene helps the brain form memories. Bubba Kush, OG Kush, and Cannatonic are used to encourage sleep and stop nightmares.

Schizophrenia. At first glance it would seem that marijuana, especially high-THC marijuana, would do more to cause schizophrenia than to relieve it, but many people who have schizophrenia self-medicate with cannabis. It turns out that high-CBD strains and high-THCV strains augment the effects of anti-psychotic medication, so it can be used in lower doses with fewer side effects. Cannabis is not, however, a substitute for antipsychotic medication. It just enables lower doses in some cases.

GW Pharmaceuticals, a drug maker in the United Kingdom specializing in marijuana research, will be testing high-CBD products as a treatment for schizophrenia in the near future. In the meantime, Cannatonic and Charlotte’s Web, taken by smoking or vaporization, seem to be the best antipsychotic strains.

I'll address the use of marijuana for seizure disorders in a separate entry.

Stress. Surely one of the most common uses of marijuana is relief from stress. On a physiological level, this isn’t surprising, since the hypothalamus-pituitary-adrenal axis in the body that regulates stress hormones is regulated by the same system that responds to cannabinoid chemicals. What is surprising is the research finding that long-term users of marijuana actually have higher levels of the stress hormone cortisol (more prominently in males than in females). The amount of marijuana use is unrelated to stress hormone levels, but the duration of marijuana use is. The more years you have smoked pot, it appears, the higher your stress levels, unless you have used only small doses on a long-term basis.

The lowest stress levels are found in people who used marijuana in a dose too small to have a psychoactive effect, less than 2 mg of THC at a time. CBD doesn’t seem to have the paradoxical effect of raising stress hormone levels, so small doses of Cannatonic, purple indicas, or Bubba Kush are best for relieving stress.

Image credit: Hanf (Cannabis sativa)
Abbildung aus Hermann Adolf Köhler: "Köhlers Medizinal-Pflanzen in naturgetreuen Abbildungen und kurz erläuterndem Texte"


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