By Janna Champagne, BSN, RN
As a holistic nurse who specializes in application of medical cannabis therapy, knowing which formulations are optimal for targeting patient’s health goals comes with the territory. After years of working with thousands of clients using a variety of cannabis products, I began noticing a trend: that the various cannabis products are not created equal in achieving optimal therapeutic results. This prompted intensive research into different types of cannabis formulations, so I could objectively advise my clients to optimal products, which led to creation of the following FLOW criteria. Please know I do not benefit from the sales of any products, so my perspective is completely objective and without profit-bias or personal gain.
In order to understand the FLOW criteria, it’s helpful to know a bit about the Endocannabinoid System (ECS). Many people, including fellow medical professionals, have never heard about this master control system in our bodies, much thanks to our recent cannabis prohibition in the US. Now that cannabis is becoming more readily accessible for research, we have learned that it contains vital nutrients needed to support optimal health balance. Cannabinoids found in the cannabis plant, such as THC and CBD, attach with ECS receptors in our bodies, which promotes internal homeostasis or balance. We know that the underlying cause of disease is imbalance, so this balancing “Entourage Effect” or synergy of cannabis may be profoundly therapeutic for improving the root cause of symptoms (4).
Following are the FLOW criteria, all of which my nurses and I deem important for safe and effective medical cannabis use. We educate these criteria to every client we serve, since our goal is ensuring that cannabis patients find the highest-quality products available.
Flower-Derived: The most potent spectrum of cannabinoids and synergistic components is found in formulations derived from cannabis flower. Since industrial hemp is sparse in flowers, often producers source oil from less optimal parts of the industrial hemp plant, such as the stalks and stems. While industrial hemp has many applicable uses, including textiles, bioaccumulation (cleans soil), building materials like Hempcrete, when it comes to medicinal potency, industrial hemp leaves a lot to be desired (9).
To clarify, many CBD producers have a USDA hemp license allowing them to legally produce and distribute hemp throughout the United States, because their cannabis flower products meet the federal hemp regulations (less than 0.3% THC). A new term, “Medical Hemp”, was recently coined by optimal CBD oil producers, to differentiate their products derived only from CBD hemp flower, the best choice for optimal quality. Medical hemp products have the added convenience of shipping legally anywhere in the United States.
Lab tested: Oregon is one of a few states that are fortunate in this regard, as they require every product on a dispensary shelf to be lab tested by a state-certified facility. Lab testing is important to know cannabinoid content, potency or strength, and to rule out contamination with toxins. Lab testing allows clients to consistently dose with improved accuracy, which is important when using cannabis for health purposes. Labs are the only conclusive method for knowing exactly what’s in a formulation, without reliance on strain name (which may not be accurate) to know which components are present.
Terpene lab results reflecting the cannabis strain’s profile are not as commonly available. When available, having this information is optimal to predict a cannabis product’s therapeutic benefits, and the terpene profile is also used to determine whether a retail product is categorized as sativa (energizing) or indica (sedating) (11).
Organic: This may seem like an obvious requirement, for those who understand the harm that toxins may cause. Unfortunately, USDA Organic certification is not yet available for all forms of cannabis farming/processing, so we rely on labs to rule out any toxic pesticide, fertilizer, mold, or heavy metal contamination. We know, especially with already sick patients, that adding toxic exposure may be harmful to their health, and could potentially negate the benefit received from cannabis. The recent theory linking Cannabis Hyperemesis Syndrome, or excessive nausea, vomiting and abdominal upset, with Neem pesticide toxicity (same symptoms) further supports the importance of using lab testing to ensure product is clear of toxins, and verified safe for medical use (10).
Whole Plant Spectrum: Products concentrating the cannabis flower as nature intended, with little to no loss, are the best option for therapeutic cannabis use. Cannabis formulations extracted using food grade ethanol or infusion methods are preferred to meet these criteria. Whole plant spectrum formulations conserve and contain hundreds of flower-derived cannabis ingredients, most of all of which remain intact in the final product. In comparison, CO2 processing nets around a dozen compounds (isolate cannabinoids + terpenes), and isolate contains only one compound (one cannabinoid). These lesser methods are popular despite research and patients outcomes clearly supporting that the Gestalt theory applies: the whole cannabis flower is truly greater than the sum of its parts (2).
Cannabis is a very complex plant, containing over 140 cannabinoids, 200 terpenes (similar to essential oils), bioflavonoids, chlorophyll, essential fatty acids, and antioxidants (1). Research supports that synergy between all of the 500+ compounds enhances the "Entourage Effect" experienced by the consumer, defined as the ability of cannabis to promote homeostasis. Many of the new and popular cannabis extraction methods in today’s cannabis industry, such as CO2 extraction, isolation, or fractionation, remove many of these ingredients contributing to the Entourage Effect (8).
It’s the balancing effect (homeostasis) that we specifically seek when the patient's goal is improved health outcomes that reach beyond superficial symptom management (4). Research comparing the efficacy of whole plant spectrum vs isolate cannabis clearly reflects that isolates, even with added terpenes comparable to CO2 and "Full Spectrum" products, aren’t as effective for exerting the balance we seek for optimal health outcomes. Research reflects that whole plant spectrum works as well or better than isolate CBD at 20-25% of the dose of isolate (or co2), thereby improving health outcomes for far less cost to the patient. Research also reflects that isolate and co2 extractions exert a bell curve response, narrowing the therapeutic dosing range, and risking little to no benefit with intensive dosing as indicated for serious conditions like cancer. In comparison, whole plant spectrum exerted a more predictable response, increasing anti-inflammatory response with higher dosing (2, 3, 6).
Another emerging issue is the increased risk of using human-altered cannabis products. This insight follows a tragic event in February 2020, when a patient using CBD for two years switched to a human-altered liposomal formulation, and immediately suffered onset of Stevens-Johnson Syndrome, a known adverse effect of her long-time medication, Meloxicam. It’s important to note that this patient did not experience any interactions between meloxicam and the first CBD formulation, despite a shared metabolic pathway (CYP450). Upon switching to a liposomal CBD, that same medication was potentiated to such an extent that she died only two days later.
Now that CBD is freely available for purchase, and most consumers don’t understand that it may interact with pharmaceuticals, this situation could repeat. This is another reason to ensure your product's effects are predictable, since we don't yet understand how our tampering with whole spectrum changes bioavailability and metabolism of cannabis with concurrent pharmaceuticals. When it comes to optimal therapeutic quality, based on my experience and the research, whole plant spectrum cannabis is the frontrunner.
For more information on FLOW criteria and a list of certified suppliers, please visit: www.cannabisnurseapproved.com
1. Echo (2017). Other compounds in cannabis. Retrieved from: https://echoconnection.org/other-compounds-in-cannabis-terpenes-chlorophyll-etc/
2. Blasco-Benito (2017). Appraising the entourage effect. Retrieved from: https://www.ncbi.nlm.nih.gov/labs/pubmed/29940172-appraising-the-entourage-effect-antitumor-action-of-a-pure-cannabinoid-versus-a-botanical-drug-preparation-in-preclinical-models-of-breast-cancer/
3. Pamplona (2018). Potential clinical benefits of CBD-rich Cannabis extracts over purified CBD in treatment-resistant epilepsy: observational data meta-analysis. Retrieved from: https://www.biorxiv.org/content/biorxiv/early/2017/11/01/212662.full.pdf
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6. Gallily (2015). Overcoming the Bell-Shaped Dose-Response of Cannabidiol by Using Cannabis Extract Enriched in Cannabidiol. Retrieved from: http://www.scirp.org/Journal/PaperInformation.aspx?PaperID=53912#.VP4EIildXvY
7. Fundacion Canna (2017) Cannabis bioflavonoids. Retrieved from: http://www.fundacion-canna.es/en/flavonoids
8. Echo (2017). CBD Alcohol or CO2 Extraction. Retrieved at: http://www.cbd-hemp-oil-drops.com/articles/57-cbd-alcohol-or-co2-extraction
9. Price, M (2015). The difference between hemp and cannabis. Medical Jane. Retrieved online at: https://www.medicaljane.com/2015/01/14/the-differences-between-hemp-and-cannabis/
10. Mishra, A., & Dave, N. (2013). Neem oil poisoning: Case report of an adult with toxic encephalopathy. Indian Journal of Critical Care Medicine : Peer-Reviewed, Official Publication of Indian Society of Critical Care Medicine, 17(5), 321–322. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3841499/
11. Cannabis Safety Institute (2014). Standards for cannabis testing laboratories. Retrieved online at: http://cannabissafetyinstitute.org/wp-content/uploads/2015/01/Standards-for-Cannabis-Testing-Laboratories.pdf
12. Han Y et al. Commercial cannabinoid oil-induced Stevens-Johnson Syndrome. Case Reports in Opthalamological Medicine. 2020.