Initiating Cannabinoid Therapy

Initiating and managing therapy with medical cannabis doesn’t need to be complicated. We’ve created this step-by-step guide to help you get started.

1) Initial patient assessment

After carefully reviewing your patient’s medical history and confirming he/she is a suitable candidate for cannabinoid therapy, you’re ready to get started.

Before beginning therapy, it is a good idea to have the patient complete a well-validated measurement tool, to use as a baseline for tracking progress. The Brief Pain Inventory is a good choice for pain patients, for example. Patients should complete this at every follow-up appointment.

Since cannabinoid therapy is still relatively new, your patients are bound to have questions. A great resource is here.

Next, you need to determine the most suitable product for their condition. We’ve created a helpful guide for you here.

2) Writing the Medical Document

Medical Documents can be downloaded from Health Canada; however most physicians find it more convenient to use the Medical Document provided by their preferred Licensed Producer. Some LP’s, like Tilray, let practitioners complete the Medical Document online. Their HCP portal also lets you confirm your patient has ordered the right product. Register for the HCP portal here.

If you choose not to use the HCP portal, patients can take a hard copy of their Medical Document home and use it to order online or by telephone.

Tips:

  • Medical Documents require HCPs to provide a total number of grams of dried cannabis per day. A maximum of 1 gram per day is reasonable for most new patients.
  • For the purposes of calculating monthly allotment only, each Tilray oil bottle is equivalent to 5 grams of whole flower (Equivalency: 8 mL = 1 g dried cannabis. 1 g/day = 30 g/month or 6 bottles of oil.)
  • Medical documents can be authorized for up to one year. For new patients, you may wish to limit duration to a maximum of 3 months to ensure they return for follow-up.

3) Patient education

Unlike pharmaceuticals, cannabis cannot be ordered and picked up from pharmacies; patients have to purchase it online and it will be delivered to their home. To save time, many doctors train their office staff to instruct patients on how to order.

4) Patient ordering

To order their medical cannabis, patients need to register with an Authorized Licensed Producer like Tilray. Patients may register & order online, by fax/mail or by calling the Tilray patient services line: 1-844-845-7291. After Tilray receives the patient’s signed Medical Document, approval takes about 24-48 hours.

5) Dosing

Dosing remains highly individualized and relies to a great extent on titration.

Currently, there are no established uniform dosing schedules cannabis and the most prudent approach is to "start low and go slow.” Due to variability with onset and duration, a starting dose of 2.5 mg THC, CBD or a combination of both is a reasonable starting point for most conditions when using oil or capsules (1.25 mg may be suitable if young, elderly, other concerns) 1.

For dried cannabis, patients should start with one inhalation and reassess after 15 minutes. They may increase by one inhalation every 15-30 minutes until desired symptom control has been achieved1. Please refer to the Sample Dosing Guidelines for more specific details based on condition.

When beginning cannabis therapy, it is advisable for patients to do so under supervision. Health Canada provides more guidance here

6) Titration

Patients should be instructed to slowly increase their dose and/or adjust their dose frequency until they find their optimal dose. For patients using ingested cannabinoids, it is reasonable to suggest increasing by no more than 2.5 mg per day every three to four days1.

For reference: When using 10:10 Balance Oil, where 1mL = 10mg of THC & 10 mg of CBD, 0.25 mL = 2.5 mg of THC & CBD.

Sample Cannabis Oil Drops Titration Schedule

DayMorning (mL)Evening (mL)Total Daily Dose (mL)
1-3 0 0.25 0.25
4-6 0.25 0.25 0.50
7-9 0.25 0.50 0.75
10-12 0.50 0.50 1
13-15 0.50 0.75 1.25
16-18 0.75 0.75 1.50
19-21 0.75 1 1.75

*Total daily intake of THC and CBD depends on the specific Tilray Drops product being ingested.
**Patients may increase dosage until they have determined their optimal dosage. Note that higher doses of THC (and CBD) are associated with an increased risk of experiencing adverse or harmful effects. Patients should be advised to immediately stop therapy and consult their physician if unacceptable or undesirable side effects occur, such as disorientation, dizziness, loss of coordination, agitation, anxiety, rapid heartbeat, chest pain, low blood pressure/feeling faint, depression, hallucinations, or psychosis.

7) First follow-up appointment

The first follow-up appointment is normally scheduled for 1-3 months after the patient begins therapy. Occasionally, a patient may request an earlier appointment if there are any unforeseen issues. However, self-titrating works well for the majority of patients.

8) Ongoing therapy

Depending on the patient’s condition and circumstances, it is advisable to see them every 3-6 months. Palliative patients or those living in long-term care will require more frequent visits, whereas otherwise healthy patients will need fewer regular follow-ups.

Download our handy Getting Started with Medical Cannabis Therapy: Pocket Guide here

References:

1MacCallum, Caroline, A., Russo, Ethan, B. “Practical Considerations in Medical Cannabis Administration and Dosing.” European Journal of Internal Medicine. (49) 2018 12-19.