This is part two of a four- part series on Cannabis and chronic fatigue syndrome (ME/CFS) and fibromyalgia (FM). (Cort added pictures and captions.)
Getting started with Cannabis
Cannabis is used increasingly to manage complex chronic illnesses and inflammatory conditions, such as MS, fibromyalgia, and cancer. The scientific literature provides strong support for using Cannabis to treat these conditions, and suggests that it may help to manage many of the symptoms of ME/CFS.
For first-time users – and even veteran ones – figuring out which Cannabis products may help, rather than exacerbate, their own personal ME/CFS and/or FM symptoms can be a daunting task. People with ME/CFS and/or FM tend to be sensitive to medications and supplements, and Cannabis is no exception. Most people have to experiment with different strains and modes of delivery before settling on products that provide the most benefit. Exercise extreme caution as you are first getting started!
Cannabis dispensaries, cards, and laws
If you live in a state where marijuana is legal, the best source to learn more about Cannabis products is in specialized stores called marijuana dispensaries. Dispensaries are typically staffed with professional and knowledgeable “budtenders” who are trained to provide guidance on how different strains and products best align with symptoms.
Some states leave it up to each county to administer state Cannabis laws; some allow for dispensaries, while others only permit sales by mail order or no sales at all. If you find yourself in a “dry” county, try the next one over. Be aware that it is illegal to cross with or ship Cannabis across state (and international) lines, even when both states permit Cannabis. One exception is CBD oil made from hemp (see below). Be sure to research the laws in your state or country before you get started.
In states where only medical marijuana is legal, a medical marijuana card typically is required. Each state differs in how medical cards are issued, whether by doctors, such as a general practitioner, clinics that specialize in issuing cards or by mail order. Some states only allow Cannabis for a very limited number of medical conditions. The cost of cards varies by state, ranging from $35-$200. Even in states which allow recreational use, a medical card may be required to access higher-THC products. Medical card holders are often exempt from excise taxes, making it worthwhile to get a card if you intend to use medical Cannabis somewhat regularly. In general, Cannabis tends to be expensive, especially the higher-quality products.
Up until recently, there has been little regulatory oversight of Cannabis production, meaning in many places, growers can still dump unhealthy chemicals on their crops. While there is no official organic certification process for Cannabis (organic certification largely happens at the federal level, where the plant is still illegal), there are many trusted product lines that adhere to organic practices. Further, many third-party certification programs are cropping up in some states with legal Cannabis, assuring organic principles are followed during production. Pesticides, herbicides, and nasty solvents, such as benzene and butane, undermine the therapeutic benefits of Cannabis and should be avoided.
Sativa vs. indica ?
The taxonomy, or scientific classification system, of the genus Cannabis is debated, and scientists and users frequently differ in how they refer to the plant. All Cannabis is probably a single species – Cannabis sativa, with different subspecies, varieties, and strains. The genus Cannabis has three taxonomic “entities” that are used for medical purposes. In the popular literature and among Cannabis users, these include C. sativa (called sativa), C. indica (called indica), and C. ruderalis (known as hemp), as well as hybrids of these types.
One of the first questions a budtender will ask is whether you prefer sativa or indica strains. Sativa is generally thought of as best for daytime use because it allows for increased focus and creativity compared to indica. However, there are always exceptions with Cannabis, and some people get very sleepy on sativa strains, suggesting that individual trial and error may be required to know if sativa vs. indica strains suit you best. Some medical uses of sativa include managing anxiety, depression, and pain.
Indica, on the hand, produces strains associated with relaxation and sleep, making it a preferred choice for nighttime use. Medical benefits of indica include increased muscle relaxation, decreased nausea, increased appetite, and decreased pain.
Hemp holds a unique place in the world of medical Cannabis because it contains virtually no THC, but does contain CBD. For this reason, hemp can be used to produce CBD oil that is legal in vastly more places. Hemp products are also available by mail order and can be shipped to most states and some countries, including the United Kingdom (products containing more than 0.3% THC are typically illegal).
Under these three broad entities, there are hundreds of different types of strains sold in dispensaries. Some strains are from indica, some from sativa, and others are hybrid strains, or mixtures of the two. There are excellent resources online, like this site at Leafly that explore the various strains in depth along with the types of symptoms each might address.
How much THC vs. CBD do I want?
The strains vary in THC and CBD content, and this ratio is very important therapeutically. Most agree that some THC is important for maximizing the effects of CBD, and CBD can also help to counter the psychoactive effects of THC. Experimenting with different products and noting the THC: CBD ratio and the effects produced is likely the best way to find the best individual fit.
To get a product with what many consider the optimal 1-3% THC content, aim for at least a 20:1 (CBD:THC) ratio to maximize benefits of both cannabinoids, while minimizing psychoactive effects. Likewise, if interested in the therapeutic effects of THC, but not the high, look for products with a lot of CBD, such as a 1:1 ratio. In general, products with more CBD cost a lot more.
How do I want to take Cannabis?
It is also helpful to consider the pros and cons behind the many different methods for consuming Cannabis when selecting a product. Typically, Cannabis can be smoked, consumed as edibles, or applied as a topical cream, which can be helpful for localized pain.
Smoking is the fastest way to get cannabinoids into the bloodstream; the effects are apparent in moments. This is something to consider for acute flares of pain where waiting hours for relief may not sound appealing. The effects of inhaled Cannabis peak within about 30 minutes and taper off after 2-4 hours. It is far easier to control the dose when smoking compared to eating Cannabis because the effects are nearly instantaneous. However, many with a chronic illness may want to avoid the adverse health impacts of smoking.
In the last decade or so, vaporizer or “vape” pens (also called e-cigarettes) with Cannabis have become very popular and offer a safer option than smoking. (Check out some reviews here. )“Vaping” involves heating Cannabis concentrates to a temperature that turns its compounds into vapor. Cannabis vaping pens can be customized by adding in specific terpenes and other beneficial compounds. There is no combustion of flowers involved, which reduces harmful tar and carcinogens. For this reason, vaping is generally thought of as being safer, but even vape pens carry risks. As with smoking flowers, the effects of vaping Cannabis are almost immediate. If you go this route, be careful to check that there are no unwanted additives.
Edibles, while better for your lungs, can take a long time to kick in, and the effects can be highly variable, even within the same person from day to day. It takes so long because it has to first pass through the liver, where it is metabolized. When Cannabis finally does kick in, it can really pack a punch, so be extra careful with edibles! Cannabis is more psychoactive when eaten because the liver converts Δ-9-THC into the metabolite 11-hydroxy-THC. In contrast, there is little metabolism of Cannabis in the lungs before it hits the brain.
Due to this lag time, it can be harder to control dosing with edibles, with people often ingesting too much without realizing until it is too late. To avoid this, practice extreme caution with edibles, starting with doses as low as a few milligrams of THC until you get the hang of it. Try not to panic if you consume too much. The high from edibles lasts much longer (4-6 hours), making it is a good choice for both falling and staying asleep if insomnia is an issue. Fortunately, most states that allow recreational Cannabis regulate the amount of THC that is allowed in edibles, making an overdose less likely.
Full-extract Cannabis oils, called FECO, are also ingested. However, they are one of the strongest products on the market. Unlike other edibles, the amount of THC is not limited in FECO, and the potential for overdose is much greater. For this reason, a medical card is typically required for FECO (even in states allowing recreational use), and extreme caution must be taken, starting with very low doses (the size of a rice grain). People who use FECO are also likely to develop a high tolerance for THC, meaning that they require more to achieve a therapeutic effect. If you go this route, be sure to get FECO made with an alcohol (vs. butane) extraction.
OTC CBD Oils and other ECS Supplements
A variety of companies make hemp-derived CBD oils with low THC levels. The 2018 Farm Bill made these oils legal in all 50 states (but beware if you live in Idaho, Nebraska, and South Dakota). (Cannabis derived CBD oils are an entirely different issue; they are still illegal in many states. That issue will be explored in the fourth part of this series. )
There is a wide range in quality of these products (the FDA does not regulate them), and some companies are simply untrustworthy. For this reason, it is essential to seek products that are third-party verified; it is the only way to know what you are getting. Dosing also varies in these products. OTC CBD oil will be covered in depth in another Health Rising article, and ProHealth has a new page devoted to all matters CBD.
Other compounds can interact with endocannabinoids and their receptors as well. For example, palmitoylethanolamide (PEA) is a dietary supplement that has been shown to have anti-inflammatory properties on microglial cells (a specialized macrophage found in the central nervous system) and is also a strong inhibitor of mast cell degranulation. There is also evidence that PEA plays a role in pain management.
Oleamide is another compound produced by the human body and is also available as a supplement. It interacts indirectly with serotonin and GABA receptors and is used as a sleep aid. Likewise, it does not interact directly with cannabinoid receptors but does increase levels of AEA.
Research has shown many therapeutic benefits of terpenes, including inflammation reduction and neuroprotection. Many other plants are high in the same terpenes found in Cannabis, such as β-caryophyllenes (found in copaiba, cloves, pepper, and rosemary), myrcenes (found in ripe mango, hops, and lemongrass), limonenes (found in citrus), and pinenes (found in pine, rosemary, and sage), to name just a few. Essential oils made from these plants may also help many of the same symptoms that Cannabis treats.
Responses to drugs can be idiosyncratic in ME/CFS and FM and Cannabis is no exception. What may be a valuable treatment option for some may destabilize others. To maximize success with Cannabis, it is important to be very cautious at the start and have a willingness to experiment a little. Also, be sure to first check for interactions with other drugs. Because Cannabis production has largely been unregulated until recently, patients need to do their own research on the quality and safety of products being considered. Cannabis is not for everyone, but it certainly helps some. If Cannabis is not for you, perhaps exploring some of the OTC and essential oil suggestions could help relieve symptoms.
Health Rising’s ME/CFS and FM Cannabis Review Program
Tried Cannabis? Want to see how others are doing on it? What works for them? What to avoid? Check out the first Cannabis Review program focused specifically on people with ME/CFS and FM
Note that all answers are anonymous. There is absolutely no way to tell who provided what answer.
Health Rising’s Marijuana as Medicine for ME/CFS and Fibromyalgia Series
- Pt I: Marijuana as Medicine for ME/CFS and/or Fibromyalgia: The Science Behind Cannabis – Amber Ella
- Pt. II: Getting Started with Cannabis – Amber Ella
- Pt. III: Cannabis – More Than Just THC and CBD – Cort Johnson – the other health enhancing factors in Cannabis
- Pt. IV: The Doctor Speaks: – Moskowitz on Cannabis / A focus on variety / Stopping the Treatment Burnout Blues / How to quickly stop a high / What to do when CBD stops working
- Pt V: CBD OIl – A Primer for ME/CFS and Fibromyalgia – Finding safe and effective CBD Oil and more
- Pt. V: Strain Specific – Picking Your Plants – coming up
Register for our free ME/CFS, fibromyalgia, and long COVID blogs here.