Dr. Dustin Sulak, director of Integr8 Health and cofounder of Healer.com, discusses cannabis dosing regimens, a sensitization protocol for chronic users, and the potential health benefits of THC’s psychoactivity. With cannabis, more isn't always better.
Project CBD: Welcome to another edition of Cannabis Conversations. I’m Martin Lee and today we’re speaking with Dr. Dustin Sulak. Dr. Sulak is a practicing osteopath. He’s the founder and director of Interg8 Health, a cannabis-oriented holistic healing practice based near Portland, Maine. There are also two other locations for the Intergr8 Health network in the New England area. And Dr. Sulak is also co-founder of healer.com, a very interesting educational website that’s chock-full of helpful information for patients and physicians. Dr. Sulak, thanks for joining us today.
Sulak: Glad to be here, Martin.
Project CBD: One issue that I think is really a challenge for both patients and physicians when it comes to cannabis therapeutics is the whole issue of dosing and how one begins a correct dosing regimen for their condition and their situation. You’ve done a lot of work in this area – kind of pathbreaking really. How do you determine an appropriate dosage recommendation for a patient?
Sulak: That’s a great question, and I get asked that question a lot. There’s really no way for someone like me, or any practitioner, to meet a patient and learn what’s going on with them and say I know exactly what you need to do in terms of cannabis dosing. It just doesn’t exist because people have such a varied response to the medicine and there’s so many different types of medicines. And from what I’ve seen in my practice, there’s this huge dosing range where some people do well with really low doses, other people do well with really high doses. There’s all the different delivery methods. So instead of trying to figure out exactly what someone should do, what I found works the best is to give someone a starting point, and then give them a methodology, a program for titrating from that starting point to determine what works best for them based on their individual goals.
Project CBD: So what might be an example? If there’s a patient who is cannabis naïve, who comes to you with a certain condition, how do you deal with that? What criteria do you use to develop a dosing regimen?
Sulak: Right. So the first thing I would do with that patient is understand if they have any fears about cannabis, because we see a lot of people that are cannabis naïve – meaning they’ve never tried it before – that are interested in it. They’ve probably known someone that’s gotten good results with it, but they’re also a little scared. So, we know that one’s mindset and one’s setting (their environment) can determine their experience with cannabis, and it can be related to side effects that they may or may not experience, if they’re set up with a positive expectation. So I like to go through and dissuade any myths, or address any fears that they might have, and at the same time figure out what that person’s goals are. So say it’s someone that’s cannabis naïve, maybe someone in their later years that has arthritic pain or low back pain, and so sure, one goal would be to reduce pain, another goal might be to improve sleep, and maybe to improve function. You know, I want to be able to play with my grandkids or I want to still be able to mow the lawn, or something like that. So we set some realistic goals. And then the first thing I would do with that patient is get them started on a dose of cannabis that’s actually sub- therapeutic. I think what works the best for the most people, especially cannabis naïve, is something they can take orally to be absorbed through the mucosa in the mouth. And they can certainly swallow a little bit and absorb some through the GI tract. So, an alcohol-based tincture or an oil, and something that we know the dosage of, we know how many milligrams of CBD, how many milligrams of THC. Typically, I would start with about an equal ratio, a 1:1 ratio for most patients because it’s very effective and very well tolerated. But if that person had a history years ago, say of having a paranoid reaction to cannabis, then I would go much higher on the CBD and lower on the THC, maybe a 4:1 or even an 8:1.
Project CBD: Would there be a situation where you might go higher on the THC and lower on the CBD in this context?
Sulak: Absolutely, Martin. Even the people that come to me that really don’t want a psychoactive experience, you know I encourage them to do that during the day; but for folks in the evening or maybe even just once a week on the weekend, I usually recommend that they do something THC-dominant to get some of that consciousness that cannabis has to offer to help them get a new perspective on their lives, to help them solve their problems creatively, and just to laugh and enjoy themselves. And also, THC-dominant cannabis sometimes just works better for people. Sometimes it works better for pain, better for anxiety, better for spasticity, and is more likely to help with sleep.
Project CBD: So when we talk about high dosing and low dosing of cannabis, what kind of range are we really talking about that you’ve seen in your practice? How low can work? How high might be necessary? What’s the range there?
Sulak: So I’ve been really surprised by what I’ve found. And part of the discovery has been really just listening to patients and they bring in their formulas, we can test them in our lab, which is part of the office. And sometimes we’re really surprised to see that some people do great with just milligrams per day – single milligrams – even as low for an adult as 1-2 milligrams a day total cannabinoids. That’s the very low end of the range that I’m seeing. And it might sound hard to believe. It’s certainly below the psychoactive threshold. But at these tiny doses, over time people find that they’re feeling better, their function is better, their symptoms are reduced. So that’s the low end. The high end for people that have sometimes failed the low and moderate dose approach, also for people that are trying to treat aggressive cancers and other severe conditions, the high end goes up to thousands of milligrams, maybe 2,000 or more per day. So we have 2 milligrams, 2,000 milligrams, and then a whole range in between which can be somewhat predictable but it varies from one individual to the next.
Project CBD: You mentioned cancer specifically, and you’ve been treating cancer patients presumably. Is it correct to assume that a cancer patient will require a higher dose, almost a priori, or are you also seeing low dose working for cancer patients?
Sulak: We’re certainly seeing low doses working to improve the quality of life in someone with cancer. And that’s always my first goal. You know we’re all going to die and cancer is going to be the cause of death for quite a few of us. So when people come to me with cancer and they’re wanting to use cannabis and wanting to rush into some kind of a super high dose because they’ve heard that’s what works best – unless it’s a very aggressive cancer and the person’s already really well experienced with cannabis, I say let’s take a month or two to work on low dosing, to really improve your quality of life and get you laughing, get you sleeping, get you feeling great. Because if someone feels great, it’s most likely that their immune system is going to be functioning well, their elimination and detoxification will be functioning well, and they can augment the healing force within them that’s already trying to address that cancer. Now during that month or two, we’ll look at a blood marker or a follow-up scan to see is this low-dose approach actually preventing the growth of the cancer. And sometimes it does. But if it’s not, and the person has gone through that low dose, then it’s time to discuss Plan B. And Plan B is usually let’s really crank up this dosage here, either to as much as you can tolerate or as much as you can afford, and let’s do that for a few months and see what the follow up tests show. Is that effective for treating the cancer?
Project CBD: So what if you’re dealing with a person who’s a long-time user of cannabis, who’s coming to you? A chronic user. It doesn’t seem like a low dose would necessarily be appropriate because that person is already using high doses. What have you found in terms of dealing with people in that context?
Sulak: This is really interesting, and it’s been a big part of the work that I’ve done. We’ve had numerous patients that are already using cannabis that come in saying this used to work better for me, how can I adjust my use to get more health benefits? And typically, the answer is to reduce their dose. I found that over time everyone has an optimal dose of cannabis where they don’t build tolerance, they get the most benefits, they get the least side effects. When they exceed that optimal dose, they start to lose the benefits over time. Then they think they need to use more. In order to regain those benefits they use more, and over time the benefits diminish even more. So I developed a 6-day protocol. I call it “the Sensitization Protocol.” And it involves two days of cannabis abstinence and then four days of very careful dose titration. And what happens, people come in, they reduce their dose by at least 50 percent over those six days. So by the end of the program, they’re using less, they’re feeling more benefits, they’re feeling less side effects, they’re saving money; it’s just great for them. And I say 50 percent, but often it’s a lot more. Something I hear quite frequently goes like, “Doc, I was smoking 12 joints a day, now I’m smoking two. And it’s stronger, it feels better, I’m getting more benefit from it.”
Project CBD: It’s a little bit counter-intuitive in a way because you think if something’s not working you want to use more. But we know about the biphasic effect, which would suggest that maybe that’s not the way to approach it. What is the biphasic effect and why is it important for a cannabis clinician and a patient to keep that in mind?
Sulak: Great question. A lot of us think more equals more in our lives. But we know that’s not always the case. And it’s certainly not the case with cannabis, based on what I’ve observed in my patients, and also based on animal and human data from research, shows that – so the biphasic effect refers to a dose response curve. If we were to plot, we give someone a certain dose, what’s their response; we give them a higher dose, do they have a higher response; an even higher dose, they have an even higher response. But then, we give them a higher dose and the response goes down; a higher dose and the response goes down again. So we have this bell-shaped curve. And it’s that optimal dose that I’m talking about which is right in the center, the peak of that curve, and once you go more you’re actually going to get less of a response. That’s what biphasic means.
Project CBD: So what about triphasic? I’ve heard that phrase recently, and I wasn’t really familiar with it. Does that also apply in terms of cannabis therapeutics from what you’ve found?
Sulak: Absolutely. Triphasic or multiphasic, because we see that it can go up and down and up and down. Each direction is a phase, right. So if I start sub-therapeutic and someone gets benefit, that’s one phase. If they go up even higher and they lose benefit, that’s another phase. But then often, when they really crank the dose up high, that benefit will return. Sometimes when it returns, it returns with side effects or the benefits may be a little bit different than they were at the low doses. And there’s probably a phase at ultra-low doses, where people can take such a small amount and get benefit down there as well.
Project CBD: So when you talk about dosing, you’re talking mainly about THC and CBD, the main cannabinoids, are you also dealing with the acid forms, the raw cannabinoids, THCA, CBDA, that actually exist on the plant – it’s only when we heat them that changes. What has been your experience with respect to the THCA and CBDA?
Sulak: I’ve been extremely impressed with the acidic cannabinoids. I used to not believe that they would do what people were saying they would do and a couple of years ago a mother of one of my seizure patients brought in a bottle of CBD that was working to reduce the seizures, and I said great let’s test it. We had just set up our lab. So we looked in that bottle. There was no CBD, there was no THC. It was all THCA, and a very small amount. And since then, I’ve been paying a lot of attention to what THCA and to some extent CBDA can do for people. And what I’m finding is that they’re effective at reducing symptoms, sometimes at a tenth or even a hundredth of the dose that it would require if they were using the neutral, or decarboxylated, cannabinoids THC and CBD.
Project CBD: And that also applies not just to the seizure patients, you also find benefits with THCA, maybe CBDA, for other conditions?
Sulak: Absolutely. I’ve seen benefits with migraine headache, benefits with pain benefits, benefits with other inflammatory conditions.
Project CBD: Is there much science that explains what’s going on here? Because we know there’s been research showing how THC acts on the brain, what receptors it connects to, given the fact that THCA is not really psychoactive like THC, do we know how it’s working?
Sulak: There’s a little science, but not much. We know that the acidic cannabinoids will reduce inflammation. And they’ve been shown in a couple animal models of nausea and vomiting to reduce the nausea at doses that are somewhere between 1/100 and 1/10 of the dose that would be required of THC. So that confirms some of my findings with my human patients – that yes, we can actually take 10 percent of their THC dose, give it to them in THCA, and get good results. We don’t believe – scientists don’t believe that the raw cannabinoids, the acidic, especially THCA, have the same mechanism of action of THC. So it’s not binding to the CB1 receptor. Its function may be dependent on the cannabinoid 1 receptor, but it’s not directly acting upon it.
Project CBD: Which sounds a little bit like CBD, maybe, in a way.
Sulak: Perhaps, absolutely. We just don’t know. There’s probably been 99.9% of the research has gone into neutral cannabionids and there’s just a small handful of studies looking at the acidic cannabinoids. We need more.
Project CBD: Let’s talk a moment about healer.com. The kind of information you’ve been sharing now, is that also available on healer.com?
Sulak: Absolutely. So healer.com is a free educational website. And we created it because we were finding that to practice cannabinoid medicine in a way that was really working for our patients, we needed to provide them with a lot of education. So there’s programs on healer.com that solve those educational needs, because not all clinicians have the 45 or 60 minute office visit luxury like we have in our practice. So we have a program for people that are brand new to cannabis and it will walk them through, step-by-step, give them a shopping guide, to really make things simple for them. We have a program for existing users, to reduce their dose using the sensitization protocol and improve the benefit; a program for people that want to switch from inhalation to tincture. So you know, all the different – a program for people that don’t want to get high. Then also we can explain to them why it might be good for them to get high every once in a while. So all the biggest educational needs that we’ve seen in our practice, we’ve put on healer.com. A really big thing that I’ve had in my practice over the last two years, has been a lot of really informed but very concerned parents wanting to use cannabis to treat their children that typically have severe neurologic conditions. So I have a whole video series on healer.com to kind of tell the parents everything they need to know when they’re considering this as an option.
Project CBD: Sounds great. Well thank you for joining us and sharing your experience with dosing and other matters.
Sulak: My pleasure, Martin.