Treating patients with chronic pain is a daily occurrence for Dr. Ari Greis, an orthopedist at Philadelphia’s Rothman Orthopaedic Institute. Many under his care are older adults, and most are cannabis-naïve. So, when he sends them to a dispensary, Greis writes clearly on the referral slip, “Do not give this patient [Rick Simpson Oil], shatter, or any other high-THC product.”
Greis has seen too many patients return from dispensaries with inappropriate products, recommended by well-intentioned but uninformed dispensary staff. “One older woman was sold a high-THC tincture she was told would help her sleep,” he said. “After waking up in the middle of the night convinced she was having a stroke, she ended up in the [emergency room]. Unfortunately, this is not an isolated occurrence.”
Perusing the offerings in Pennsylvania dispensaries, Greis discovered the number of products he considers medically appropriate for his patients is startlingly low. “There were any number of THC-only products, many of them extremely potent,” he said. “But products with any CBD content were very poorly represented.”
Where is the CBD?
Dr. Laurie Vollen, a California cannabis physician, echoes his frustration. With a patient population that skews toward the elderly, Vollen finds local medical dispensaries have little to offer. “I often recommend inhaling a high-CBD strain of flower to my patients for treating breakout pain and other conditions,” she said. “Particularly when it comes to flower, amidst the dozens that are available, finding high-CBD strains can be very difficult.”
The overwhelming majority of older adults who use cannabis medicinally do not want to experience any intoxication, nor do they have to. Cannabis specialists like Greis and Vollen are usually able to help their patients achieve symptom relief using only very low levels of THC. And CBD, with its anti-inflammatory and anxiolytic properties, is an important component in the cannabinoid-based medicines they recommend.
A dispensary survey
Curious to see whether the dearth of CBD-containing cannabis products was unique to his locale, Greis and two colleagues conducted a survey of dispensaries across the United States. He presented the results as a poster at a recent meeting of the International Society of Cannabinoid Researchers in Bethesda, Maryland.
The team evaluated 158 online dispensary menus from twenty-seven states, including those where adult-use is legal. About five dispensaries per state were chosen, with urban and rural areas included. The team reviewed 22,998 products including concentrates, topicals, tinctures, edibles, flower, and vaporizers. Specifically, they looked to see how many products on the menus contained some amount of CBD.
The survey revealed only 19.5 percent of the products contained any level of CBD. When adult-use states were excluded from the picture, the results were virtually the same across the 12,118 products evaluated: 19.4 percent.
As Greis observed, recreational market menus and medical market menus look pretty much the same. “Essentially, only about 20 percent of the products have CBD in them,” he said. “And when you break it down, you can actually see that what we considered to be the most medically appropriate cannabinoid profiles were the sublinguals, the tinctures, capsules, and some of the topicals.
“Most of the inhaled products were lacking CBD and contained what we would consider to be very high levels of THC,” he continued. “It’s kind of an arbitrary assessment, but there are lots of products that have 70 percent to 90 percent THC and no CBD. We now have a situation where, in dispensaries across the country, over 80 percent of the products on sale are of medical utility to only a very small percentage of patients.”
Regulation inconsistency
Dr. Stephen Dahmer, chief medical officer at Vireo Health, a Minnesota-based multi-state medical cannabis company, takes exception to the survey’s findings. “This is definitely not the case in our dispensaries or the ones I oversee,” he asserted. “We cover the entire spectrum of high-THC, high-CBD, and one-to-one products, so I’m a little surprised about that data. We don’t even have a THC-only product.”
In New York, for example, where Vireo operates, a cursory survey of dispensary menus seems to validate Dahmer’s point. Products featured by many dispensaries fit somewhere on the range between high-THC and high-CBD, but always with both cannabinoids present. The fact that selling dried flower, which makes up a large portion of many dispensaries’ THC-only products, is illegal in New York, may skew the state’s results, though.
Ryan Lepore of Empire State NORML explained New York is unique in ensuring there is a specific CBD-to-THC ratio as the distinguishing factor between product lines. According to Rod Kight, an attorney specializing in cannabis law, “New York medical marijuana regulations require that dispensaries make available at least one brand of marijuana product that has low THC and high CBD content and at least one brand that has approximately equal amounts of THC and CBD.”
Vireo’s Dahmer also noted that, among the majority of patients his dispensaries see in medical states, the most common reason for using medical cannabis is chronic pain. “And we certainly see not only from the robust data, but also from the crowd-sourcing, that it is the THC-dominant medicines that are more frequently used, and more efficacious, for chronic pain,” he said.
DIY medicine
Back in Pennsylvania, Greis has found products containing CBD that are available in dispensaries rarely contain amounts exceeding the single digits per serving—levels that are notably low compared to those commonly recommended with hemp-derived CBD products. Hemp-derived CBD products are not permitted in Pennsylvania dispensaries; the same is true in many other states. While CBD derived from cannabis has the advantage of being regulated and tested, the cost per milligram can be prohibitive, especially compared to hemp-derived CBD products available online. For patients on limited incomes, the difference in prices makes the choice for them.
Entirely omitting THC from treatment regimens can produce less-than-optimal results, though. Greis has found patients tolerate medication with low THC and a significant amount of CBD much better than medication devoid of THC. So, for those he believes could benefit from a larger overall dose of cannabinoids that won’t be debilitating or financially prohibitive, Greis may recommend they mix their own medicine.
“When I realized what they are charging for CBD in the dispensaries in Pennsylvania, that’s what really motivated me,” he said. “I did the simple math and found it’s ten times more expensive than ordering from a good, reputable supplier that can provide a healthy dose of CBD for less than a dollar a day.”
Specifically, he recommends patients purchase a THC-only tincture in a dispensary and a concentrated CBD product from a reputable supplier online. Then, with his guidance on dosage, the patient combines the two.
Clearly, this kind of home-concocting isn’t appropriate for everyone. Particularly for older adults, whose eyesight may be poor and hands unsteady, the task could prove onerous at best. Ironically, older patients are prime candidates for “mix-your-own” cannabinoid medicine therapies.
The bottom line
As long as there is demand for high-THC products, companies will continue to grow and produce them and dispensaries will continue to supply them. But as research into the myriad medicinal properties of cannabis continues apace and more applications for cannabinoid-based medicines are discovered, a significant shift in consumer patterns toward older adults appears already in the making.
As Eli Melrod, founder of Sebastopol, California, dispensary Solful, related, seeing the lack of CBD-rich products in his state’s dispensaries motivated him to address the market need. The strategy is paying off. “We are seeing a growing demand for these types of products, as many of our customers are looking to use cannabis as an alternative to pain medications, sleeping medications, and many other addictive pharmaceuticals with myriad side effects,” he said.
Breakthroughs in research, along with the extraordinary popularity of CBD and a growing pool of compelling personal experiences, have resulted in an increasing openness among older, cannabis-naïve patients to a new kind of plant-based medicine. For many conditions, the optimal results entail a significant dose of CBD balanced with at least some THC.
In the meantime, in Greis’s view, the main role for high-THC products is in treating some extreme, painful conditions such as cancer, or for people who have developed tolerance, which he suggested they should work to reduce. But as he pointed out, a majority of patients, and particularly the elderly, simply don’t need them.
“When the state steps up and begins requiring emissions testing and starts shutting down the black market, the good players in the industry will be heavily rewarded,” he said. “Fortunately, we are seeing black market companies fade away, and hopefully within five years we will see a completely regulated market.”
