Due to drug interactions, there is a safety risk with CBD products in some patients . The utility of CBD-dominant products may improve safe cannabis initiation as it is considered non-impairing. There is limited evidence that CBD may counter adverse events related to THC, although commonly done by some clinicians in practice. It is important to note that many CBD dominant products will contain some THC. For example, if a patient is taking 50 mg of a 50:2 CBD dominant product, they will still receive a 2 mg dose of THC. This may be a consideration when increasing doses, particularly in patients sensitive to THC. However, with a slow titration approach most patients will develop tolerance to the relatively small dose of THC. Once chemovar and route of administration have been selected, patients should be initiated with a low-dose, slow titration regimen . To reduce risk of impairment or adverse events, clinicians may consider dosing based on the mg of THC, not percent concentration.
A slow dose titration can help to build tolerance to THC and reduce the risk of adverse events and impairment. To optimize safety, the goal is to reach the lowest dose that offers symptom control with minimal or no adverse events. From a safety standpoint, consider a CBD dominant product first for daytime use. This is especially important in medically vulnerable populations. If THC is needed, start at a low dose at bedtime, and slowly titrate up. If daytime THC is needed, it should be added slowly to the initial CBD-dominant treatment regime until goals of therapy are achieved. At time of cannabis grow system initiation, we recommend keeping all concomitant medications doses stable, unless it is known to interact and monitoring warrants adjustment. Following initiation, monitoring is an essential component to ensuring safety. The monitoring frequency depends on prior cannabis experience, comorbid medical conditions, and the patient’s ability to adhere to the treatment plan .
Generally, the initial follow up is set within 1-3 months of starting medical cannabis. Special populations often need more frequent follow up. If the patient has any of the conditions listed in Table 1, consider initial follow-up every 2-3 weeks until the patient is on a stable dose. If a patient has minimal experience, moderate to severe comorbidities, or difficulty adhering to the treatment plan consider initial follow up within 1 month of initiation. If the patient is an experienced user, has minimal comorbidities, and is able to adhere to the treatment plan following up within 3 months of initiation is usually appropriate. Clinicians should adjust recommendations based on their experience and the patient’s condition. Cost of medical care may influence a patient’s monitoring schedule. CRCs should be aware of the guidelines set out by their regulatory body. Similar to many countries around the world, regulations related to cannabis have been evolving in the Maltese Islands in recent years. The 2015 Drug Dependence Act provides for the prescription of medicinal preparations of marijuana grow system by registered specialist consultant physicians in situations where a ‘viable alternative’ does not exist.
Moreover, the section in the Drug Dependence Act on the use of medicinal preparations of cannabis was amended and elaborated in 2018. At present, a licensed medical practitioner, who is duly registered under the Health Care Professions Act, may prescribe medicinal preparations of the cannabis plant, as well as synthetic cannabinoid products that are licensed under the Medicines Act or manufactured under Good Manufacturing Practice. The law additionally highlights that the preparations should not be indicated for smoking , and that medical cannabis preparations are only to be dispensed by a pharmacist within a licensed pharmacy. Another landmark piece of legislation, the 2018 Production of Cannabis for Medicinal and Research Purposes Act, allows for entities to cultivate, import, process and produce cannabis intended for medical and research purposes. There is considerable interest in cannabis and cannabinoids for medical purposes. However, it is not without concern about potential risks, evidenced from numerous scientific reports.1 Indeed, across countries and health professions, research shows that medical, allied health and social care professionals need to have the adequate knowledge and skills in order to advise patients and clients on the positive and negative impacts of medicinal cannabis preparations.In addition, knowledge about the attitudes of such professionals toward medical cannabis use is important for policy and clinical service provision. For example, a study of US medical students showed that medical students tend to support cannabis legal reform, medicinal use of cannabis, as well as increased research.