What dose should I give my patients?

What dose should I give my patients? The most difficult thing for a doctor is to determine the dosage for medicinal cannabis. Leading Maltese doctor advocating for a better understanding of the medicinal properties of cannabis, Dr Andrew Agius, knows how. In his pain clinic on Malta he treats patients with challenging chronic pain conditions, like fibromyalgia, who have tried many different types of medications and have not found relief from their symptoms.

Dr Agius shares his dosing experience with us: “It’s very simple. Always start with the lowest dose possible, tail up the dose very slowly over many days until symptoms are relieved. Adjust the dose to find the right balance between effective relief of symptoms with least side effects.”

How is prescribing cannabinoid therapeutics different to prescribing conventional medicines?

“The dose varies greatly from patient to patient and needs to be adjusted from time to time. Cannabinoids target the endocannabinoid system which is involved in many of the body’s functions. So by using one medicine, doctors can help relieve various unrelated symptoms with minimal side effects.”

Dr Andrew Agius 1

What are the key benefits of cannabinoids as a therapeutic product?

“It provides very effective relief from pain symptoms with very little side effects compared to the other available medications. Most side effects are positive unlike most other medications. This could include less anxiety, better sleep, better mood and better control of chronic conditions such as diabetes, asthma and eczema.”

Which form of administration do you advise?

“I advise vaporizing the dried flower that is available in pharmacies as this provides legal, quick, safe and effective relief of symptoms. They can also combine it with a safe CBD oil product which has been recommended from a trusted supplier, taken as sublingual drops.”

Most doctors are not trained in the use of medicinal cannabis. How did you familiarise yourself?

“I learnt by reading a lot from the internet. I enrolled into online educational courses and went overseas to conferences and educational meetings. When I felt confident enough, I prescribed and recommended various types of medicines to my patients and through the feedback they provided, I learnt more and more on how various cannabinoids effect different patients and relieve various symptoms. This kind of patient feedback helped me improve on various treatment strategies to obtain better results.”

Western medicine is entirely based on scientific evidence that requires randomized, double-blind placebo-controlled studies. Unfortunately, there is still not enough evidence. And that’s why doctors are reluctant to prescribe. What would be your comment on that?

“I fully agree that there are not enough randomized, double-blind studies to provide the same evidence that backs the use of other types of medication. However, cannabis has been used over 5,000 years and we know that it is extremely safe and it has shown to be very effective in many different types of medical conditions, especially conditions where conventional medication was not effective. From my experience over the last two to three years, I have very strong observational evidence that medical cannabis is very effective for most of my patients, especially patients suffering from disabling chronic pain conditions such as fibromyalgia which are very difficult to manage by using available registered medicines.”

Do you have any advice for doctors starting out prescribing?

“Since it is very safe to use and it is now legally available, if you have a patient that has tried medications to relieve chronic pain or other disabling symptoms with minimal effect, start by prescribing a low dose to these patients and see how grateful they will be that you have made a significant improvement in their quality of life.”

Medicinal cannabis on Malta

In Malta, every registered doctor can prescribe medical cannabis. If a patient suffers from a chronic illness and has tried at least one medication which hasn’t been effective, they are eligible to try medical cannabis. The doctor makes an application to the Superintendent of Public Health requesting her permission for the patient to use the medicine. If the patient has never attended an opiate detoxification program in the past, the application is approved for thirty days. Following this thirty-day trial, the patient needs to go back to their doctor who prepares a medical report and another application which is then approved for six months. The patient needs to be reviewed every six months and each time a new approval is granted by the Superintendent of Public Health. There are four medicinal cannabis products available on Malta, this includes Bedrocan® (THC 22% | CBD <1.0%)  and Bediol® (THC 6.3% | CBD 8%).

Your pain clinic is an integrative medical centre for the holistic management of persistent pain. What do you mean by that?

“Persistent pain is chronic pain for more than three months which greatly effects patients’ quality of life. Holistic management means integrating a biopsychosocial approach to managing such patients and supporting them in all areas of their life not just by providing medication. We give advice on lifestyle changes, improving sleep routines, increasing physical activity, adjusting the diet and reducing stress through mindfulness meditation and yoga and also psychotherapy when indicated.”

Logo of Pain Clinic Malta

What makes your approach special?

“We adopt a very conservative approach and start by prescribing physical activity, a healthy diet and mindfulness-based stress reduction before considering medication or more invasive measures. When prescribing drugs, we opt for the safest, most natural alternatives that promote natural healing and effective relief from symptoms with minimal side effects.”

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