Part IV of our “Marijuana as Medicine for ME/CFS and Fibromyalgia Series” focuses on a general Cannabis treatment approach.

Health Rising’s Marijuana as Medicine for ME/CFS and Fibromyalgia Series

The Doctor Speaks

Dr. Michael Moskowitz is a pain doctor in Sausalito who sees the worst of the worst. He’s generally the end of the line for people in chronic pain.  The author of “Medical Cannabis: A Guide for Patients, Practitioners, and Caregivers”, he’s also on a mission to convince patients and the medical establishment that Cannabis is worth a try.

Cannabis - for medical use only

Used correctly, Moskowitz and others report that Cannabis products may be able to relieve pain, improve sleep, reduce anxiety and improve cognition.

While recognizing that randomized, placebo-controlled studies are rare, Moskowitz asserts that plenty of information, in the form of animal studies, pharmacological studies and case reports, indicates that when used properly, Cannabis is a safe and sometimes quite effective treatment for a wide variety of issues.

In a recent Leafly interview, Moskowitz explained the frustration he’s felt over 30 years of inadequate pain treatment.

“I was treating patients for probably thirty years when I came upon this [Cannabis] in chronic pain treatment, and what I was impressed with was how muddy all of the medicines we were using were. Even though we got people better, we never got anybody well or rarely got anybody well. The rubric in chronic pain treatment is to tell the patient, ‘we can help you reduce your pain but we can’t make it go away’. I thought, that’s just crap, why are we telling people that? We’re only telling them that because we don’t have the tools that we know how to use to make it go away, but it doesn’t mean they don’t exist.” Moskowitz

Moskowitz’s personal experience with Cannabis began after a devastating injury resulted in four surgeries on his ankle and lower leg. With opioids having little effect on his pain, he tried something new:

“I started using more cannabis with higher THC because I was doing nothing but laying around at that point… I came up with a treatment where I used a combination of THC and CBD in an alcohol tincture in a rollerball, rolled around the area where the surgery was because I couldn’t touch it, it was still an open wound, and it took the pain away 100% within three minutes. It never failed to do that, not once.”

The effect would last from six to eight hours. At that point, he began slowly incorporating Cannabis treatments into his practice and created a database that followed 161 people over 19 months. He had worked with many of the patients for years.  The results were remarkable in a practice such as his: eighty-seven percent reported pain reduction, 81% reported improved sleep, 73% improved stress, and 76% improved quality of life.

Norman Doidge reported on Moskowitz’s use of neuroplasticity to reduce his patients’ pain, but in a recent interview, Moskowitz stated that Cannabis was producing a more robust response.

The Case for Synergy

There’s this tremendous synergy that makes up that ensemble or entourage effect. Moskowitz


Knowing only the THC and CBD content of a strain is limiting; it takes away the blending of the entourage effect and doesn’t help in recommending something based on its medical values. Moskowitz

THC and CBD do different, sometimes even opposing, things in the body, but when it comes to healing, they work better together than separately.  Studies suggest that when taken alone, CBD is usually less effective than when taken with THC (and other phytocannabinoids).

While CBD is the most anti-inflammatory substance yet found in Cannabis, other phytocannabinoids in the plant have their own and differing anti-inflammatory effects. Combining them into one more potent anti-inflammatory package seems to make sense in ME/CFS/FM.

Cannabis more is better

With Cannabis, using more constituents of the plant usually works out better,

If fact, one study suggested that taking CBD alone greatly reduces its window of efficacy: i.e. you have to get just the right amount to relieve pain.  Animal studies suggest that with pure CBD oil, less is more, and increasing the dose beyond a certain point does not help relieve pain. This plateau effect did not, however, occur with full-spectrum Cannabis extracts.

The same appears to be true for THC.  Backes reported that a CBD/THC spray called Sativex significantly reduced cancer pain while pure THC did not.

Note that as much attention as THC and CBD have received, they’re just the beginning of the medicinal story regarding Cannabis.  The other phytocannabinoids (CBN, CBG, etc.) and chemicals in the plant (terpenes, linalool, etc.) also have medicinal effects and, if possible, should be included in one’s treatment regimen. (Because less of these factors are found in hemp-derived CBD oil, Cannabis-derived CBD oils may work better.)

Marijuana as Medicine for ME/CFS and FM III: Cannabis – More Than Just THC and CBD


 A Focus on Variety

Openness to trying new approaches can be quite helpful. The advantage of a constantly shifting internal and external mix of endocannabinoids and phytocannabinoids is that the body does not become tolerant to any one approach, making it harder for disease to express itself in the face of this constantly adjusting treatment.  Moskowitz

Moskowitz believes that, for medical purposes, the methods of delivery which provide the broadest sweep of phytocannabinoids possible are tinctures, vaporized plants and capsules. His recommendation that one start out with tinctures and then incorporate other delivery methods into one’s regimen fits well with his general approach to incorporate as much variety into one’s regimen as possible. This ultimately includes using different strains and different modalities (tinctures, oils, vapor, capsules, topicals, raw plant).

Stopping the Treatment “Burnout” Blues

Focusing on only one component or strain of the plant is limiting and gives too much chance for the treated illness or injury to adapt and overcome effectiveness. The body’s ability to do this is an unfortunate fact of most treatments. Mostkowitz

Moskowitz believes that Cannabis may be uniquely positioned to deal with a common problem in ME/CFS, fibromyalgia and other diseases; treatments which are effective at first but which peter out over time. Cannabis’s ability to keep producing effective results when other medications have failed may lie in three factors: the many different strains of the plant, the many routes of application available, and the many systems it affects suggests to Moskowitz that when used skillfully, Cannabis may be able to, in effect, nudge the body out of illness states that it’s become mired in.

In chronic conditions, the body resets to survive within the relentlessness of the disease. With a treatment that constantly shifts its own milieu and the body’s internal milieu, combined with such broad-based anti-inflammatory and neuroprotective traits, we have a real chance of making fundamental changes. For the patient, then, establishing effective care, then trying new and varied products can be extremely helpful. Moskowitz

Moskowitz also draws a distinction between stronger but shorter-lived responses and slower, more profound responses.

The true gift of this treatment is in its ability to transform the body back to normal states in a slow, methodical way. This slow nudging back to normal is the best way to move from a state of disease to that of wellness because it allows the body to slowly adapt…to establish a new and lasting balance point of health and pleasure…Moskowitz

When CBD Oil Stops Working

This article suggests that while it is possible to build up a tolerance to THC, it’s not as likely to happen with CBD. Still, reports indicate that this can happen. Oddly enough, one of the solutions to CBD tolerance is to take less of it.

Other options include giving yourself a short vacation (2-3 days to a week) from the plant. Trying different strains and/or different delivery methods is recommended as well.

Taken too much THC? It's possible to quickly reverse the process.

Taken too much THC? It’s possible to quickly reverse the process.

How to Get Rid of an Unwanted High

  • Take a high CBD / low THC tincture and then hang on for the 60-90 minutes it will take for it to take effect. (CBD inhibits THC activity.)
  • Or for quicker relief, vaporizing a high CBD / low THC strain should knock that high (or anxiety, etc.) down in 3-5 minutes.

According to Backes, high THC Cannabis with CBD, limonene and pinene may be less prone to producing anxiety. A plant with 10% CBD and 5% THC will generally produce no intoxicating effects. Mixing a plant with 10% THC and little CBD with one that has 15% CBD and little THC will likely also produce no intoxicating effects.


Cannabis oil

Drop of Cannabis oil.

CBD oil is probably the easiest and safest form of Cannabis to use and is the form many beginners start with. The 2018 Farm Bill is making THC-free (or nearly free) CBD oil legal just about everywhere. CBD oil, however, is not without its risks. With some companies looking for a quick score, cheap and possibly even unsafe forms of CBD oil can be found.

Getting Your CBD Oil

CBD oils are derived either from a particular strain of Cannabis called hemp, which by definition has very low levels of THC, or from other strains of Cannabis which have higher levels of THC.

Hemp is Cannabis gone industrial. Believed one of the earliest cultivated plants, this spectacularly fast-growing plant has been used to make clothes, shoes, ropes, paper and other products for thousands of years.

A cash crop planted by most of the U.S.’s founding fathers (Thomas Jefferson,[122] James MadisonJames MonroeAndrew JacksonZachary Taylor, and Franklin Pierce), hemp fell awry of the authorities in the 1930’s when, after being wrongly lopped in with Cannabis, a special tax was placed on its production. Lifting the tax during World War II (“Hemp for Victory”) caused industrial hemp acreage to soar, but the Controlled Substances Act of 1970 classified hemp as an illegal Schedule I drug and hemp acreage in the U.S. dropped to almost nothing.

The 2018 Farm Bill changed all that. It allows for broad hemp cultivation and the transfer of hemp-derived products (including hemp-derived CBD oil containing less than 0.3% THC) across state lines for commercial or other purposes.

Hemp-Derived CBD Oil

The U.S. is already the largest consumer of industrial hemp in the world but until recently has produced very little hemp, leaving China the big dog in the hemp marketplace. The 2018 Farm Bill, though, which removed hemp from the Controlled Substances Act and reclassified it as a commercial product, is going to change that big time.

U.S. farmers are reportedly eager to start growing this versatile, fast-growing,  and tough plant. Besides being a source of a growing industry, hemp has quite a few things going for it. For instance, it requires much less water than corn, needs no pesticides and tolerates a wide variety of soils.

Hemp-derived CBD oil can present some issues, though. Hemp contains very low amounts of CBD, which means it takes a lot of hemp to get CBD from it. (High CBD hemp strains are being developed.) Because so much extraction is required, one should be doubly sure that non-toxic extraction methods are being used. Hemp’s soil-tolerating capability can be a double-edged sword as well.

Hemp is a bioaccumulator; in fact, it’s so darn good at absorbing toxins from the soil that it was reportedly used in Chernobyl to clean up the soils there. Hemp’s ability to thrive in and clean toxin-contaminated soils may prove a real boon for environmental restorationists, but it presents challenges for those wishing to use hemp-derived CBD oils.

The Gist

Buying CBD Oil

Full-spectrum CBD oil which contains more medicinal factors is generally more effective.

Cannabis derived CBD oil is probably best as it contains more medicinal compounds and is more tightly regulated.

Hemp derived CBD oil, however, is more widely available and is likely to become even more widely available after the 2018 Farm Bill made hemp derived products legal throughout the U.S.

Because hemp is a bioaccumulator purchasing hemp derived CBD oil from China is not recommended. Organic sources are probably best.

CBD oils that have a Certificate of Analysis (COA) from a certified lab which describe plant constituents and contaminants are recommended.

Only buy CBD oils that have been extracted using alcohol or CO2. Other extraction types may leave toxic residues.

When vaping avoid cartridges which have toxic thinning agents (e.g. propylene and/or ethylene glycol), flavor additives, etc.

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Leinow reports that “many” industrial hemp-derived CBD products are grown in China on soils of uncertain origin. Plus, some producers use solvents such as butane and hexane in the CBD extraction process, which can leave toxic residues behind.  One 2014 analysis from Project CBD found dangerous levels of hexane in random samples of CBD products derived from hemp.

Because hemp is not a regulated substance, you also don’t always know what you’re getting.  A study published in the Journal of the American Medical Association found that 26% of CBD products researchers purchased online contained less CBD than labeled and 43% contained more. (Oil-based products were more likely to be accurate.  Twenty-one percent of CBD-only samples actually had some THC in them.) 

Testing revealed that some hemp derived CBD oils had wildly varying amounts of THC and CBD with some “CBD” oils containing no CBD at all. Some leading hemp derived CBD oil brands which advertised their full-spectrum oil nature had only one cannabinoid present – likely markedly reducing their effectiveness.

Plus, Project CBD reports that some hemp-derived CBD oils contain unhealthy additives such as corn syrup, artificial flavors and colors, and other contaminants.

Beware Imposters in the Cannabis field

The Cannabis Science Fibromyalgia Pain Patch: Fact or Fiction?

Note that because hemp also contains substantially lower levels of the terpenes believed to be an important medicinal part of Cannabis, you may not get the full entourage effect available from hemp-derived CBD oils.

This is not at all to say that hemp-derived CBD oil cannot be effective. Properly produced hemp-derived CBD oil can work well and has the bonus of being available in states which have not legalized marijuana or don’t support medical marijuana. Given the changes produced by the 2018 Farm Bill, we are likely to see more and more hemp-derived CBD oil over time.

Project CBD and Consumer Reports suggest some ways to find safe hemp-derived CBD oil.

  • Consumer Reports recommends buying American – CBD derived from hemp grown in Colorado, Kentucky, Oregon, Vermont, Tennessee, etc.
  • Consumer Reports recommends buying from companies located in states, which, because they have legalized recreational and medical cannabis use, tend to have stricter standards.
  • Look for companies which contract with third-party testers which surpass state requirements for CBD oil testing. These testers should be able to identify cannabinoid and contaminant levels. They should have a Certificate of Analysis (COA) from a certified lab which shows the results of those tests.
  • Buy hemp grown in accordance with certified regenerative organic standards. (This standard goes beyond FDA organic standards to require sustainable farm practices and animal safety.)
  • Avoid CBD hemp oil vape cartridge products that have toxic thinning agents (e.g. propylene and/or ethylene glycol), flavor additives, etc.
  • Buy products that show CBD/THC content per serving – not per bottle.

Cannabis-Derived CBD Oil

Extracting CBD and THC from Cannabis is a much simpler proposition because of the much higher CBD and THC levels found. In general, Leinow argues that Cannabis-derived CBD oil is a better bet because Cannabis is more highly regulated and includes more compounds that contribute to its healthful effects.

Extraction Methods

CBD oil is extracted from Cannabis in several different ways. Alcohol extraction is a low-tech and safe method. Supercritical fluid extraction using CO2 is another non-toxic method that has become the gold standard for producing safe concentrates.

Butane extraction, on the other hand, is popular but can leave toxic residues and the RSO extraction methods uses toxic solvents. Both should be avoided.

Health Rising’s  Fibromyalgia and Chronic Fatigue Syndrome Cannabis Review Program

when you get it right
you pass it on… 
Gary Snyder

Cannabis review program

Check out the first ever ME/CFS/FM focused Cannabis Review Program.

The first Cannabis review program for people with ME/CFS and/or 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

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