Do’s and Don’ts of Medical Marijuana in South Africa

Gustav Boshoff

Pharmacist at SimonsHoogte and Blue Rose Outreach

Ever considered using medical marijuana in South-Africa?

Here are the reasons to consider it or to rather not, in which dosage form and how to acquire THC containing medical marijuana in South-Africa (lawfully).

Reasons for:

I think the medical reasons for are covered extensively in many articles such as Medical marijuana – Mayo Clinic or 7 Potential Health Benefits of Cannabis | Johnson & Wales University

But I will just give my real world experience and opinion on where it shines. Medical marijuana should not be in place of your medical treatment, but it could be a great supplement, or in rare cases the full treatment of certain conditions.

Treatments are in many cases only as good as the patient’s perception of how well they work, and in that light, not many medications shine as well as marijuana! But this will only be the case for some patients. Why is that? Well, it comes down to the personal experience that a patient will have. This is the real problem that hinders medical marijuana as a treatment plan, in my opinion. People will have their thoughts and physical biases towards medical marijuana.

Thought in the sense that two individuals can have vastly different opinions about cannabis before using it. Physical experiences of the high that is brought on by cannabis differ from person to person. The variation does not stop there, as the effect from different strains and dosage forms also have vastly different highs as well as medical benefits from them.

How do you know if it is the choice for you or a loved one? Well in my opinion, you will only really know if it is for you or not after using and gauging. But start low and go slow.

Let’s break it down:

First of all, be honest why you would consider using medical marijuana and it is ok if one of the reasons is that you feel calmer, more creative, more in tune with your own mental state, feel good and if you do not enjoy the experience but still want to enjoy the medical benefits of medical marijuana, be honest about it and consider using a different dosage form or different strains.

To not be at risk of gesturing broadly at all of mental health, let me focus on one use; and it’s a goodie! Anxiety from Post Traumatic Stress Disorder (PTSD). The poster child of mental health issues treated with medical marijuana. This treatment is not a silver bullet treatment, as in some cases using marijuana while you are anxious is a sure way to make you more anxious! Thus this actually sounds bad as a treatment but it goes deeper than that. Probably the biggest contributor to the overall PTSD symptoms can be drawn back to the fact that these people suffer from bad sleep cycles. They suffer because they witnessed something so severe that their brain struggles to comprehend it. Our brains will nonetheless try to comprehend it, and we organise these thoughts while we sleep. Because these events are traumatic in nature, it is possible that the patient just can’t process and make true peace with it. So, the result is that these patients end up dreaming about that event and/or similar events. These dreams can, in themselves, be traumatic to live through.

So, how do we address this? Well, cognitive and exposure therapy done with the patient will help them process these events and are crucial, but we can help these patients even more with medical marijuana.

I am guessing that most people are not aware that the Ukrainian Army is a big procurer of medical marijuana. Although I have not found any research results of the treatments yet, I believe we will see some good studies coming out soon that will back the use of medical marijuana in PTSD.

So, how does it actually work? Well, this is where the Indica dominant and Sativa dominant thing actually comes into play. Indica: calm and relaxed. Sativa: focused and energised. Well, in someone with anxiety, focused and energised will most likely lead to focusing on the anxiety, which is, fair to say, not great. But with an Indica dominant strain used at night time… We are getting somewhere.

Most people with PTSD suffer at night time. Sleeplessness and traumatic dreams occur almost every night for these patients. This leads to anxiety at night time. Using an Indica dominant medical marijuana will make the patient calm and relaxed, which leads to having less anxiety and quicker initiation of sleep. But there is a second layer as well. Marijuana has a side effect. It stops you from dreaming. It does this by increasing your time in deep sleep and decreasing your time in REM sleep. And REM sleep is where we dream.

This means that our patient does not have to worry about fighting demons all night! If you consider this vs other treatments, it is better than sleeping tablets and alcohol which can cause dependance and exacerbate the problem.

https://www.bbc.com/news/world-europe-66877717

https://www.ewn.co.za/ukraine-to-legalise-medical-cannabis-to-treat-wartime-ptsd/

Being open minded about the experience that you have helps you think critically about whether it was good or bad for you. Unfortunately, no doctor or auntie can look into your eyes and tell you with 100% certainty that something is for you or not, and I implore you to assess your experience.

Do you know that your mental state of mind plays a much bigger role in your eventual experience of the medication than in any other medication? In my experience, your setting is super duper important. For me (who is both an intro- and extrovert) this triggers my introverted notions. When I have marijuana I don’t want people around, maybe close friends or a partner. I have tried using it at a social gathering and have realised that I just do not enjoy it. Most people I have encountered feel something akin to this, and then others thrive on being high around people.

So, I would recommend being honest about what you like. If you enjoy your own company, do not use this medicine in a social climate but rather use it in the comfort of your safe space.

CBD

So, what if you don’t like the feeling of a high but still want the benefits? Easy! Just change your dosage form and medication. I know an elderly couple that don’t enjoy being high and smoking something is just out of the question! So, they make tea. They enjoy full spectrum cannabis just before bedtime and this helps them sleep and helps with the auntie’s arthritis. They also claim they wake up in a good mood, and it shows!

If you do not enjoy the thought of your mind being altered even if you sleep through it, then you might want to try CBD or CBD dominant strains.

Yes, CBD is the non-psychoactive cannabinoid that also comes from cannabis. It is available in South-Africa at your local pharmacy on the shelf, or if you actually want an effect from it, you need a script from a doctor. Now, in my opinion, how they approved over the counter CBD in South-Africa created the perception that CBD does not work. Well, yeah, in the way it is approved, of course it’s not going to work.

Two reasons: It is too weak, and it needs an entourage effect. CBD is approved for sale in two ways in South-Africa and only one way for THC (sort of).

CBD is approved as a schedule 4 medication and a schedule 0 complementary medication.

Schedule 4: Any dosage or dosage form that you need. This is the route I would advise to use if you want to try CBD, but the doctors are not always clued up on the exact strains that are available and in what dosage forms. Some doctors might not even be clued up on CBD or THC at all, as this is a new medication, even for them, but do listen to the doctor as they do know everything about your condition. So, to streamline the procurement, go to the dispensary first and listen to the pharmacist to gauge what is in stock and what is going to be best for you. Then, go to the doctor with that recommendation.

CBD is also approved as a schedule 0 complementary medication. This means that it is available on the shelf. This is limited to a maximum of 20 mg CBD per day, and a maximum of 600 mg per dosage unit. Dosages range from 10 mg to 1500 mg per day. 10-20 mg per day is a good place to start, as we always advise with cannabinoids to start low and go slow, but in my experience, for most conditions it just isn’t enough. I would also always advise to use a full spectrum CBD; the entourage effect is just undeniably better.

To get an idea of CBD dosage please look at these websites:

THC

Ok, let’s say you are interested in something that has the potential to make you goofed. THC for medicinal use is scheduled in South-Africa as a schedule 6 medication. What this means is that it has strict control measures, but it is completely legal to purchase when prescribed by a doctor and sold by a pharmacist in a registered dispensary.

The SAHPRA CEO sums it up beautifully in this video:

SAHPRA CEO demystifies Scheduling of THC and CBD (Cannabis)

Now comes the fun part. I would argue that there are about the same amount of strains on the market as there are types of yoghurt. Choosing between them looks daunting, but just ask your pharmacist and/or doctor to help you. To start you off, the biggest choice is to choose a Sativa dominant, Indica dominant, or something in the middle. Pure Sativa and Pure Indica are no longer available, therefore a Sativa today is Sativa dominant, and the same for Indica. To summarise a very broad range of options: Sativa gives positivity and energy, and Indica gives sedation and relaxation. Now, these are stereotypes and, yes, for most cases this is true but is not a rule, and there are exceptions to this all over. Do your own research of what might be the right one for you, and phone cannabis dispensaries to find out what they have in stock. Then, discuss this with the pharmacist and doctor. But, just like any medication, one will only really know if it will work or not when used, so, if it’s not for you, then stop using it completely or try a different strain.

Some good guidance on commercial strains is discussed on this website:

https://risecannabis.com/cannabis-101/indica-vs-sativa/

The Entourage

So, what are the entourage chemicals? Well, it’s all of the other cannabinoids that are also present in the medicinal marijuana product, besides the main cannabinoid that you are taking, as well as the terpenes that are present. There are more than 100 identified cannabinoids, each one with a minor or major effect on the endo-cannabinoid system. In total, there are about 540 different chemical components in the average cannabis plant. The main cannabinoids, THC and CBD will, of course, appear at the top of the list in big, bold letters, but these are far from the only important guys in the mix.

These include, but are not limited to: CBG, CBN, CBC, THCv, CBDA, CBG, as well as terpenes. Each one of these brings something to the party, either by its own effect or by potentiating (make stronger) the effect of another medicinal chemical. In my opinion, THC and CBD only work to their maximum potential if they are surrounded by other chemicals. Basically, if it is a pure distillation of THC or CBD, it is akin to 100% alcohol; to get the best results it needs to be combined with other components. In cannabis’s case it is usually the entourage chemicals that make all the difference in the effect that one gets from the medicine.

Figure of different cannabinoids effects

https://www.claybourneco.com/blog/what-are-cannabinoids-definition-effects-and-benefits

Then, there are also the terpenes. Terpenes are the biggest contributor to the different flavours in cannabis. They are, per gram, also the most expensive part of distillates, if you are using cannabis derived terpenes. Besides flavour, they are an essential part of what medicinal and/or recreational effects we can expect with different cannabis strains or ingredient combinations. Terpenes have a wide range of beneficial effects, and they really work best if they are all in combination with other medicinal compounds such as THC, CBD etc. I will always suggest using a full spectrum THC or CBD product, as the effects it has in practice are just amazing.

Figure of different terpene effects

https://cannacon.org/15-terpenes-cannabis-explained/

So, it feels that there is too much choice. Yes and also no. So yes, there are a multitude of medicinal compounds in medicinal cannabis, and the concentrations of the different medicines means that there are an infinite number of variations. You could mix all of these different ingredients to achieve different effects. But, you know what is also like that? Cooking. If you like sausages, the sausage itself could be made in so many different ways and you could also use it as is, or cut up as part of different meals. Now, predictably, if you make the sausage that you like in another meal that you like, you should end up liking that meal as well (except if you overcook or burn your sausages).

So how do I start?

Step one:

Find information from a trusted source. The internet is a good source of information, but please verify your “facts”. It’s like streams of water. It’s best to filter before consuming. And the best way to filter it? Go speak to someone who actually knows the subject matter. Your pharmacist or doctor might not use medical or recreational marijuana, but they do know what is and is not good for your body and your condition. They are also unbiased in the matter, as their main goal is to stay reputable, not sell you their product. But please do a bit of the leg work and find out what is on the market, and then ask the pharmacist or doctor what they think of it, or ask them to look into it for you if they do not know it specifically. Pharmacists actually love looking up new treatments. It’s what we do.

Step two:

If you are happy with a strain, please just check in with your dispensary and find out if they have that strain and/or dosage form in stock, or if they can order it for you if you get a script for it. See, for the dispensary to procure the legal medical marijuana, they have to buy the marijuana from a GMP (Good Manufacturing Practice) certified facility. This ensures the quality of the medicine, as the facility that the product comes from is inspected and regulated by SAHPRA ,and not just bought from a guy growing it in his basement. So bear in mind, the available strains at your dispensary will not be all the different strains that exist, but there should be more than enough variety to find at least the next best thing.

Step three:

Discuss your decision with your doctor, and get a script for the specific strain and dosage form that is available at your dispensary.

Step four:

Get the medical marijuana from the dispensary.

Step five:

Use as directed.

Sources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8333608/

https://www.mayoclinic.org/healthy-lifestyle/consumer-health/in-depth/medical-marijuana/art-20137855

https://www.jwu.edu/news/2021/09/7-potential-health-benefits-of-cannabis.html

https://purecraftcbd.com/blogs/news/cbd-doses-what-to-expect-at-25mg-100mg-300mg-500mg-and-2500mg

https://www.verywellmind.com/cbd-dosages-how-much-cbd-should-you-take-5078580

https://youtu.be/jtY9zgDWElk