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A physician’s perspective on optimal cannabis dosing

February 26, 2018
(contrastaddict/iStock)
Dosage is the key factor in achieving the most benefits and least adverse effects of cannabis. After following thousands of patients using medical cannabis for eight years, I’ve observed that dosing cannabis is unlike any therapeutic agent to which I was exposed in my medical training. A basic understanding of the key characteristics of cannabis dosing can empower you to make the most of this incredibly versatile, safe, and effective herb.

Some patients effectively use tiny amounts of cannabis, while others use incredibly high doses. I’ve seen adult patients achieve therapeutic effects at 1 mg of total cannabinoids daily, while others consume over 2,000 mg daily without adverse effects. And while a 2000-fold dosing range is unusual for a medication, researchers have failed to kill monkeys at doses even 300 times higher than the highest dose I’ve observed in the clinic.[i]

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Multiphasic dose-response relationships

Within this unusually broad dosing range, cannabis exhibits an unusual relationship between the dose and the expected response.  For most medications, a higher dose will result in a stronger therapeutic effect and a higher likelihood of adverse effects; this is described as a monophasic dose-response relationship. Cannabis simply does not follow this pattern.

For most cannabis consumers, gradually increasing their dose will at first result in stronger effects; but after a certain point (unique to each individual), subsequent dosage increases can result in weaker and weaker therapeutic effects, accompanied by an increase in unwanted effects.

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Consumers who continue to increase their dosage to very high levels can often reclaim some or all of the previously lost benefit, and sometimes find additional therapeutic effects not achieved at the lower doses. Of course, ultra-high doses are much more expensive and usually produce more unwanted side effects. Most patients do much better at the lowest effective dose.

The medicinal benefits of cannabis may start to diminish as the dose is increased. (Dr. Sulak/Healer.com)

For many cannabis users, this means that less can be more. In a study of 263 opioid-treated cancer patients with poorly controlled pain, the group receiving 21 mg of combined THC and CBD each day experienced significant improvements in pain levels, more so than the group that received 52 mg daily. The group that received 83 mg daily reduced their pain no better than placebo, but experienced more adverse effects.[ii]

Cannabis has the ability to produce opposite effects in different people, with different strains, and at different dosages.

How is this possible? The endocannabinoid system is a sensitive, highly tuned physiologic infrastructure designed to maintain balance at a cellular level. When the cannabinoid receptors become overstimulated by high doses of cannabis, the cells pull the receptors inside, where they are either recycled or degraded.[iii] As cannabinoid receptor levels diminish, the effects of cannabis will diminish as well, even (or especially) in the face of dose escalation. This is known as “tolerance-building,” something that many regular cannabis users have experienced.

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Therapeutic window

The term “therapeutic window” describes the range between the lowest effective dose and the dose that produces unwanted or intolerable side effects. People who have little or no experience using cannabis typically have a very narrow therapeutic window, while regular users develop a wider therapeutic window.  This is due to the fact that individuals build tolerance to the various effects of cannabis at different rates, and most build tolerance to the unwanted effects faster than the desired effects.

Bidirectional effects of cannabis

Cannabis also has the ability to produce opposite (or bidirectional) effects in different people, with different strains, and at different dosages. For example, anxious people who take cannabis may relax while non-anxious people who take the same dose can become anxious. The same dose of two different varieties of cannabis can cause opposite effects – one might be an awakening strain and the other might put you to sleep.

When combined, CBD and THC can enhance each other’s benefits while reducing unwanted effects.

Interestingly, the symptoms of cannabis overdose closely mirror the symptoms one would expect cannabis to relieve at appropriate doses: nausea, vomiting, diarrhea, sweating, spasms, tremors, anxiety, panic attacks, paranoia, discoordination, and disturbed sleep. Extreme overdoses can lead to hallucination and even acute psychosis.

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Fortunately, these symptoms are all self-limiting, and most people return to their normal selves within 12 to 24 hours. Even though a cannabis overdose may make a person feel like they’re dying, such an experience will cause no toxicity or permanent damage, except perhaps in people who have unstable cardiovascular or psychiatric conditions, or in the case of impairment leading to an accident.

Combining CBD and THC

CBD and THC have many overlapping therapeutic qualities, including relief of pain, anxiety, seizures, and nausea, although they work via different mechanisms of action.  When combined, CBD and THC can enhance each other’s benefits while reducing unwanted effects, including the psychoactive or impairing effects of THC. This is great news for cannabis users who want health benefits while maintain optimal performance at home or work.

Ultra-low doses of cannabis can be extremely effective, sometimes even more so than the other extreme.

By adding CBD to THC, the therapeutic window, described above, becomes even wider. Consumers should know, however, that the total dose of cannabinoids needed to treat a symptom or condition will also likely increase.

For example, in a study of 177 patients with cancer pain, one group received an oral spray of THC, while another group received an oral spray of combined THC and CBD at an approximate 1:1 ratio. Both groups were allowed to gradually increase their dose until they experienced satisfactory relief. The THC group ended up using an average of 27 mg daily, while the CBD+THC group used close to 60 total mg daily, but the CBD+THC group had a superior reduction in pain.[iv]  I’ve seen this in many patients–combine CBD and THC for optimal benefits, but be prepared to take (and purchase) higher overall dosages.

Ultra-low dosages

Some patients do well with ultra-high doses (hundreds or thousands of milligrams daily). THC consumers have to slowly work up to these high doses, but many patients can quickly reach high doses of CBD without adverse effects. On the other hand, ultra-low doses can be extremely effective, sometimes even more so than the other extreme.

Most people are surprised to learn that the therapeutic effects of THC-dominant cannabis can be achieved at dosages lower than those required to produce euphoria or impairment.  Cannabis microdosing, taking a non- or slightly psychoactive dose for the purpose of improving heath and productivity, has been gaining popularity.

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Microdosing cannabis: Benefits without the buzz

People report better mood, reduced anxiety, improved focus, enhanced resilience to stress, less pain (and/or less bothersome pain), and other benefits without any adverse effects. Most consumers find that 1-5 mg works well for this purpose. Some emerging evidence even suggests that a practice like this could be protective against the damage of a heart attack[v],[vi] or brain injury![vii],[viii],[ix]

Recommendations for new and experienced consumers

For new cannabis users, I abide by an old adage I learned from one of my geriatrics instructors: “Start low, go slow, and don’t be afraid to go all the way.” I’ve developed an easy- to-follow program to help find your optimal dose, along with other useful resources like a medical cannabis shopping guide, available free on Healer.com.

For existing users who may have built some tolerance to cannabis, I encourage you to try my 6-day sensitization protocol, which has helped thousands of people reduce their cannabis dose by 50% or more while improving the benefits. If you haven’t tried non-inhaled delivery methods such as tinctures or sprays, and if you haven’t experimented with the combination of CBD and THC, I suspect that both of these endeavors will help you continue to unlock the full power of this incredible herb.


[i] Thompson GR, et al. Oral and intravenous toxicity of Δ9-tetrahydrocannabinol in rhesus monkeys. Toxicology and Applied Pharmacology. 1974;27(3):648-665.
[ii] Portenoy RK, et al. Nabiximols for opioid-treated cancer patients with poorly-controlled chronic pain: A randomized, placebo-controlled, graded-dose trial. The Journal of Pain. 2012;13(5):438-449.
[iii] Hsieh C, et al. Internalization and recycling of the CB1 cannabinoid receptor. Journal of Neurochemistry. 1999;73(2):493-501.
[iv] Johnson JR, et al. “Multicenter, double-blind, randomized, placebo-controlled, parallel-group study of the efficacy, safety, and tolerability of THC: CBD extract and THC extract in patients with intractable cancer-related pain.” Journal of Pain and Symptom Management. 2010;39(2): 167-179.
[v] Waldman M, et al. An ultra-low dose of tetrahydrocannabinol provides cardioprotection. Biochemical Pharmacology. 2013;85(11):1626-1633.
[vi] Johnson-Sasso CP, Kao D, Walker LA. marijuana use and short-term outcomes in patients hospitalized for acute myocardial infarction. Journal of the American College of Cardiology. 2016;67(13):569.
[vii] Fernández-Ruiz J, Moro MA, Martínez-Orgado J. Cannabinoids in neurodegenerative disorders and stroke/brain trauma: From preclinical models to clinical applications. Neurotherapeutics. 2015;12(4):793-806.
[viii] Nguyen BM, et al. Effect of marijuana use on outcomes in traumatic brain injury. The American Surgeon. 2014;80(10):979-983.
[ix] Di Napoli M, et al. Prior cannabis use is associated with outcome after intracerebral hemorrhage. Cerebrovascular Diseases. 2016;41(5-6):248-255.

Dr. Dustin Sulak's Bio Image

Dr. Dustin Sulak

Dustin Sulak, DO, is the founder of Integr8 Health, a medical practice in Maine that follows over 8,000 patients using medical cannabis; Healer.com, a medical cannabis patient education resource; and Cannabis Expertise, a continuing medical education curriculum. Recognized as a leading clinician in the application of medical cannabis, Dr. Sulak is committed to providing education to clinicians and patients on the use of medical cannabis.

View Dr. Dustin Sulak's articles

  • johnsabo1234

    this is exactly why we need more research on the subject. I am tired of asking potheads what kind of marijuana I should get for my medical condition.
    Most dispensaries are filled with useless potheads. Sorry to sound harsh. We need better treatment and better medicine.
    I am voting no on legalization.

    • JoelGray

      Voting no on legalization only hinders research.

      But I get what you mean. I hate going into my local shop looking for something geared to take the edge off my nausea, and being sold something that I’m told will “make you feel like you’re riding a bicycle.”

      Luckily, now that our state has combined rec/medical sales, now only the best budtenders get jobs. Even the ones who only started smoking weed to get high are knowledgeable about the array of symptoms it can treat and what products to use.

      TLDR it seems like legalization might actually alleviate your issues with the industry as it is now.

      • Mark Page

        They’re sales people not Dr’s.

        • JoelGray

          No sh*t. But without legalization, NOBODY— even doctors— has access to the science that details how to treat yourself effectively.

          I’m lucky. Broke as I am, I had the time and disposable income to experiment until I found the strains and applications that worked well for me. Many people don’t have that luxury.

          • Mark Page

            We all have the same google. Legalization has nothing to do with available information.

          • JoelGray

            So much well packaged “science” about cannabis is based on nothing but extremely limited, anecdotal evidence. And it will continue to be so until scientists can access research funding without the threat of losing their livelihoods.

            Google can be very, very wrong— and when it comes to something like weed, it very often is.

          • Mark Page

            Google is a search engine, it is neither right or wrong lol. I go top CA and NV dispensaries so don’t try to tell me the science isn’t there. Some of those people amaze me at what they know. Furthermore marijuana has been researched with government and private funding for years so why does it have to be legalized now for research to continue?

    • Mark Page

      They’re sales people not Dr’s. You have online capabilities right? You are the one being a useless pot head, and a lazy one at that

      • YoungSword

        This is so true…..we can’t blame them the age research is on US…
        In the end YOU ARE YOUR OWN DOCTOR….Everyone else …including Doctors are just ADVISORS.

    • Akamal

      Your point is one that I can not stress enough to people. I have had many decades of recreational marijuana use (not as a heavy user) but stopped because of concern about damage to lungs and the newest pot just made me stupid and was so strong I could only enjoy it at rare occasions.
      For the first concern, I now vape only dry herb (so that there is nothing I don’t know) but more importantly, I have a medical prescription and have tried various medical marijuana strains or hybrids with controlled THC and CBD. These less potent, but balanced THC CBD strains give such a different effect that it should be treated as a different drug.
      Unless it is a social situation or I really want to get stupidly high (which has not happened yet) I will not touch the recreation pot-head marijuana anymore. I don’t know how to properly describe it, but for an alcohol analogy, it would be the difference between having a single serving of a top-end aged alcohol versus chugging a bottle of screech made in someone’ s garage. Even as I write this, I think “yech”.

    • Abdul Adams

      Most of those potheads know better than any gov’t agency and why would you vote No on legalization. That defeats your whole purpose.

  • jimbro44

    Legit article! (EDIT: EXCEPT for the 6 day sensitization protocol which leafly is letting you hawk on their page… why I have no clue. Had it been free info, sure. But “Member Login Required?”? You should be ashamed sir! And Leafly as well!!! How do you have an ADVERTISEMENT in an article with sourced to medical articles? Conflict of interest much? Wow… anyway back to my OP)
    Thank you Dr. And also for the sources…
    I’ve suspected the difference in sativa v indica and leafly’s ‘fact or myth’ article on this echoed your points on it affecting people differently and also that the main difference is not sativa v indica but that rather indicas usually have more cbd, causing stronger and or more sedating effects in MOST people.

    You are clearly very educated on the cutting edge research and I look forward to reading further articles.

    I (edit: WAS) also very interested in seeing your 6 day sensitization protocol.

    Very interesting micro v mega dosing, individual respond and the sources!

    Well picked Leafly, and extremely well written Dr. Dustin Sulak!

    • Jody L. Erickson

      A more holistic approach is key. Any serious dispensaries, who want to legitimize the industry, would be progressive to create a setting where holistic health practitioners work with the staff and customers to help identify what will work best for each individual, with follow up, etc. Physicians would likely be more supportive of their patients’ use of cannabis and thus more successful treatments.

    • its free. the membership is free. i just downloaded it. they just ask for the “membership” bc of all the hard work they put into it. all they ask you for is an email. it is an exchange your email for their good information and energy is all 🙂

  • JaxJr

    I like the article because it talks about cannabis. He brings to light that smoking high levels of THC in our cannabis has become an art for those that want High strains. We have three strains Indica sativa and your blend hybrids. Go low don’t smoke all day it’ a mood changer. Go high smoke all day.

  • Réal Guy

    Why do i come back here only to find delete posts??

  • Big Cat Cannabis

    As a Master of Oriental medicine it is not surprising that a western Dr would not be exposed to dosing herbal medicine while in school. That said, there are combinations of herbs both Western and Chinese that can mitigate any down side as well as enhance Cannabis in therapy.

  • Grow Your Own

    Very Interesting Article by the Good Doctor. Lots of Information & techniques to delve into.

  • DrCatMD

    Excellent article, i see similar results with my patients. That multiphasic dose response and bidirectional effect of MMJ on patients is real,, definitely start low and go slow! Then titrate to wellness… we definitely can always work on strain specificity and personalize what works best for you. Cannabis brings together my favorite parts of medicine, safe medications, the best patients and precision medicine (n=1)

  • Loren Wiener

    This is something we are seeing a lot in the not quite fake media. How odd to see a story about using “THC and CBD” in Cannabis but ignoring the words “full spectrum” or natural ratio, It ignores that here on Earth 1 – Cannabis is 10-20:1 THC:CBD so why not test natural ratio being the benefit of that was discovered in 1966 and 1:1 ratios (per the article being successful) were actually discovered in 2001 to only be 1/15th or 1/10th as successful in trials and acknowledged since as patients are using 10 to 15 times the suggested dosages since. The 1:1 product invented by Bayer-Monsanto / GW Pharma UK and marketed since 2003 is called Sativex. The goal of the pharma industry that is trying to gain traction on Real Cannabis for medical use is to somehow introduce “new products” that are Cannabis like, as they cannot market real Cannabis can they – Too many false prophets seeking false profits off the back of those that want real Cannabis for medical use here in Australia and further afield. <3

  • Julie Jungwirth

    soooooo….I grew up in the 70’s done my share of the doobie. Throughout the years I partook here and there, socially, not really all the time everyday. My brother is stage IV cancer, has been a pot smoker for a long time, now mainly to sleep, and I am helping him on his journey now. He’s been on the oxy for pain, finally got the card and hit the local dispensary. Young kids trying to be helpful but, not the type of connection that is clicking, its all new and that’s ok. I will be checking in on this thread, sounds like a lot of good info. Would love to get some good old hash for him to try…