In our trial, we're looking at about two grams of herbal cannabis a day. We do find that it's not uncommon for people to return that. We ask them to return whatever they don't use in a given day and sometimes they will bring some back. It's not like everyone is using all of their two grams per day.
Having said that, I do hear of cases where people do respond well to larger doses, as Dr. Thirlwell was discussing. I think the science is still unclear about what a maximum dose is. One thing we do know about cannabis and the endocannabinoid system is that it's what we call allostatic, which means it kind of regulates itself, so as you use more cannabis, you develop a tolerance and you need more cannabis to get some of the same effects.
That can lead to the tolerance and withdrawal that some people characterize as addiction. I want to use some caution about using the term “addiction” when we talk about medical cannabis users. There is a tolerance and withdrawal. It resolves itself more quickly than withdrawal from things like SSRIs, benzodiazepines and a number of widely used medications.
I want to caution the use of the term “addiction” in a medical context. The cannabis withdrawal syndrome is pronounced. There's no doubt that it exists, but it's also pretty mild in terms of the consequences and the difficulty people have giving it up. It's addictive, perhaps, the way that coffee is addictive, rather than the way that opioids or alcohol are addictive. There is a habit-forming aspect of it, but when we use the term “addiction”, it carries a lot of baggage. I just want to caution the use of that term when we talk about cannabis. There's a withdrawal and tolerance and I think one of the concerns about higher doses is that it can exacerbate that withdrawal and tolerance. That doesn't mean it's necessarily unmanageable. There are ways of titrating people down if the dose gets too high.
I do think it's worthwhile to consider those lower doses and see if people can't get the best effect at a lower dose. Perhaps, as we ramp it up, that can interfere with the optimal lowest possible dosing.