Updated: Mar 5
In August 2021, Higher Learning LV conducted an exclusive interview with Sunil Pai, MD, a celebrated clinical practitioner, author, and holistic healer who leverages the efficacy of botanical medicines to produce positive outcomes for his patients and readers.
Other popular articles in the Higher Learning LV Interview series include:
August 2021 Interview with Sunil Pai, MD
Pai is an internationally recognized expert in integrative medicine based in Albuquerque, New Mexico and author of the critically acclaimed 2016 book An Inflammation Nation. He is a lecturer and a contributing author to medical textbooks and scientific journals.
Sunil Pai, MD
Pai is a practicing doctor who combines an evidence-based approach with 20 years of clinical experience. Each year, he educates thousands of physicians and medical professionals about the nuanced biochemistry involved in the administration of hemp-derived cannabinoids and terpenes for the treatment of a variety of disease states and conditions.
Below, Higher Learning LV™ interviews Pai regarding the popular topic of cannabidiol (CBD) dosing.
The Higher Learning LV™ Interview
Higher Learning LV™: "Why is dosing so important for gaining the maximum benefit from broad-spectrum hemp extracts?"
Dr. Sunil Pai: "Dosing is ultimately the key factor that provides the positive and anticipated response from broad-spectrum hemp extracts. Unfortunately, dosing is misunderstood by many health providers and patients. Both have been taught from their experience with pharmaceuticals (which are single-agent ingredients and single-receptor targets) that there is a dose response curve."
HLLV: "Let's talk more about the dose response curve and the dynamics of this physiological mechanism."
SP: "Most wellness practitioners and consumers are acclimated to a dynamic equating higher doses with a greater response. However, with CBD from hemp oil, it is quite the opposite. Peer-reviewed research defines, and clinical experience demonstrates, that the CB1 and CB2 receptors of the endocannabinoid system are more in an ‘active state’ when there is more tissue damage, dysfunction, or imbalance versus a ‘resting state,’ which is what occurs in healthy tissues.
"Thus, when a person experiences a health issue, CBD receptors are more active and less dosage of CBD is needed to stimulate those receptors and turn on a cascade of reactions for supporting inflammatory and immune repairing mechanisms.
"Most health providers are not recommending CBD dosing appropriately to achieve the maximum benefit. Most providers and patients are taking larger doses than they actually need and therefore missing what I call the ‘sweet spot’ of having these receptors activate optimally. It is like a key needed to open the door. You only need a small giggle at the lock to open it and enter the house. You don't need a bulldozer to knock the door down. More CBD is not always better. Less maybe best for most. However, more frequently taken throughout the day works better than larger single doses daily."
HLLV: "What process must a consumer and their wellness practitioner go through to properly dose?"
SP: "'Start low and go slow' is my approach which works best. I recommend beginning with the lower potency tincture bottle first and taking 1/4-1/2 dropper sublingually, three times a day and at bedtime.
"Start at this dose for at least seven days. If benefits are not observed, the daily dose should be increased by 1/4 dropper. Again, wait for about seven days. The consumer should maintain a journal of their symptoms and any potential side effects they may experience. After the consumer feels that they have achieved a noticeable improvement in their symptoms, they should attempt to go one dose higher. If they notice a diminishment of benefits or increase in side effects, then they should return to their previous dose.
"One of the most import aspects for the practitioner is to encourage the consumer to be patient during this process. Unfortunately, many providers and consumers are excited to use broach-spectrum CBD from hemp oil. This often involves them starting with larger single doses in an attempt to achieve immediate results.
"However, through this approach, the consumer usually does not achieve the maximum benefits. They are more likely to decrease compliance of using CBD overtime as they never achieved their intended benefits."
"However, through this approach, the consumer usually does not achieve the maximum benefits. They are more likely to decrease compliance of using CBD overtime as they never achieved their intended benefits.
The CBD molecule
"I recommend starting with tinctures first, due to quicker onset and control of dosing. If a consumer ends up taking more than one dropper per dose, after they finish the bottle, I recommend a higher potency bottle. This makes it easier for them to consume and is a more cost-effective approach in the long run."
HLLV: "Subjective efficacy is a big concern of wellness professionals. What if a consumer experiences issues when beginning consumption of a tincture? What other options are available to them?"
SP: "If a consumer is at a higher dose of a tincture and experiences issues, I may switch them to capsules. Capsules directly help with GI conditions. But in order to achieve maximum benefits (for both tinctures and capsules), the practitioner should recommend a whole food, plant-based diet to ensure anti-inflammatory foods and fiber. This supports the microbiome to ensure proper functioning and utilization of CBD."
An Inflammation Nation by Sunil Pai, MD
HLLV: "Many wellness practitioners claim that dosing is a moving target. How often does a consumer need to 'recalibrate' their doses of a hemp extract to ensure maximum efficacy?"
SP: "Just as with all medications and dietary supplements, their absorption, assimilation, and excretion is affected by the state of health of the individual. Important factors such as the microbiome, liver function, and the consumer's immune function and overall inflammatory conditions will affect how their dosing may change over time.
"To reduce potential problems, sublingual tinctures of broad-spectrum CBD extracts help provide a better rate of immediate absorption, unlike capsules, which require about 45 minutes for onset and to begin taking effect.
Another tip: After taking a tincture sublingually, leave the mouth for about 30-45 seconds and then swallow. Try not to eat for about 15 minutes. This maximizes absorption and contact of the CBD hemp oil with mucosal membranes for best bioavailability.
"Another tip: After taking a tincture sublingually, leave the mouth for about 30-45 seconds and then swallow. Try not to eat for about 15 minutes. This maximizes absorption and contact of the CBD hemp oil with mucosal membranes for best bioavailability.
"Consumers may need to recalibrate their doses of hemp extract if they have any changes to managing their symptoms or changes to their health such as weight loss or gain, GI issues such as colitis, gastritis, fatty liver, etc. Again, if the consumer notices that they are not obtaining the benefits of using their CBD as they did before, I would still recommend them to restart at a lower dose and titrate upwards, versus just increasing from what dose they are currently using."
HLLV: "In your own clinical practice, what have you noticed when consumers get too high or too low a dose?"
SP: "In cases of dosing that is too low or too strong, consumers do not get the full benefits. If they take too low a dose, they may not experience benefits. The side benefit is they may feel more relaxed, calm, and sleep better.
"Their inflammation maybe improved, but not as much as we would like. This is one reason that increasing dosing slowly, over time, is key. Taking too low doses is better than too much. Again, consumers must increase dosing slowly to find the titration that works optimally for them and their particular physiology and health level.
"When consumers take too high of a dose they may notice feeling tired or sometimes nothing at all. Again, they may likely perceive that they need to increase their dose to feel something."
"When consumers take too high of a dose they may notice feeling tired or sometimes nothing at all. Again, they may likely perceive that they need to increase their dose to feel something. But too high a dose, with most consumers, means they have overshot the sweet spot and are missing the full benefits they could be experiencing.
"Most consumers who take high doses usually do so only one time a day, at bedtime, for example. They usually will report they slept a bit better, but their overall symptoms won't change much because CBD from hemp oil works better with smaller, more frequent doses. That’s really the takeaway; smaller, more frequent doses of CBD are better for many consumers."
HLLV: "Is tolerance building a characteristic of CBD and other cannabinoids in broad-spectrum hemp extracts? If so, how do you deal with it in your practice?"
SP: "Building tolerance can be an issue with full-spectrum CBD extracts, which contain a maximum of 0.3 percent THC, especially for sensitive consumers or those with metabolic issues or other health issues (i.e. fatty liver).
"Because broad-spectrum products contain no THC, tolerance it not an issue. The issue is not so much about building tolerance, as people have experienced with other medications like pain medications such as NSAIDs and opioids. Rather, it is more about the consumer's state of health. As their health improves, CBD receptors turn down into a 'resting state.'
"At this point, more CBD might be needed for the user to experience a difference. Whereas, when users are experiencing severe health issues, those CBD receptors are in the 'active state' and, thus, smaller doses of CBD are needed to gain maximum benefits."
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