Understanding Tolerance breaks for patients

What is a tolerance break?

A tolerance break (often referred to as a ‘t-break’ or ‘cannabis holiday’ in the cannabis community) is when a patient stops their use of medicinal cannabis treatments for a period of time to reset their cannabinoid receptors and get the most out of their medication. 

Regular use of THC-containing cannabis medications can cause patients to develop a tolerance to the therapeutic benefits of their treatments, meaning they may stop experiencing the same results or relief that they usually would with their regular dose of medication.¹ 

A tolerance break helps counteract this effect by resting and resetting the receptors in the patient’s body that interact with medicinal cannabis treatments so they can return to their preferred dose or even lower to achieve their desired therapeutic benefits.

Understanding cannabis tolerance

When prescribing medicinal cannabis to treat the symptoms of a medical condition, the goal should always be to find the right type of treatment for the patient – including the format, cannabinoid content, terpene profile, and dose – to help your patient find relief while maintaining a sense of homeostasis or balance within the body. 

All of these factors vary depending on the needs of each patient, and what works best for one patient may not work for another patient’s symptoms or physiology.

You may prescribe your patients any combination of CBD-only treatments, THC-only treatments, or combined treatments containing both CBD and THC, as well as other minor cannabinoids (such as CBG or CBN). 

The way these cannabinoids affect each patient and impact their tolerance varies depending on how they interact with the patient’s endocannabinoid system (ECS). The ECS is the molecular system responsible for regulating and balancing many processes in the body – including immune response, communication between cells, sleep, digestion, stress, pain response and more. The ECS is made up of cannabinoid receptors, endogenous cannabinoids (endocannabinoids), and the enzymes responsible for the synthesis and degradation of the endocannabinoids.

Let’s look at the different ways CBD and THC interact with the ECS and affect cannabis tolerance.

CBD tolerance

Cannabidiol or CBD is one of the most abundant in a long list of cannabinoids found in the cannabis plant, alongside THC. Unlike THC, CBD won’t bring on a feeling of being ‘high.’ CBD is known for its calming effects on the body, with potential therapeutic benefits ranging from relieving anxiety and depression to reducing seizures, pain, inflammation and more.

We know that the cannabinoid CBD has a narrow side effect profile.² It’s non-impairing,³ and because it works indirectly, rather than directly, with our ECS (and binds only weakly to cannabinoid receptors) there is little risk of CBD causing an imbalance or flooding the ECS. 

This means that patients will likely be able to maintain their ideal dose of CBD without building up a tolerance, developing unwanted side effects or needing to adjust their dose too much. If a patient consumes CBD-only treatments, they may benefit from taking breaks to reset their system and help maintain the effectiveness of their treatments. 

There is a very low risk of experiencing withdrawal symptoms during a CBD break.

THC tolerance

When it comes to THC, things work a little differently. THC is a psychoactive, intoxicating cannabinoid that acts directly upon the body’s ECS⁴ by stimulating cannabinoid receptors (CB1 and CB2) thereby causing changes in our CNS. THC’s potential therapeutic benefits range from pain and nausea relief to reducing inflammation, anxiety, insomnia and more. Because the ECS is responsible for maintaining balance and harmony in the body, the effects of THC will be dose-dependent. Meaning the correct dose of THC can help create balance, while too much THC over too long a period of time can cause an imbalance. 

Not only that, but research has shown that regular users of THC-containing cannabis treatments develop a tolerance to both the impairing effects, as well as the therapeutic benefits of the plant over time. This means that patients who consume THC may start to notice they are not achieving the same level of relief as their usual dose after a period of consistent use.

Thankfully, this built-up tolerance is not a final, permanent state of regular cannabis consumption, but rather a temporary state of decreased sensitivity to cannabis that fluctuates depending on the pattern of cannabis use. This means that patients can reset their cannabis receptors, lower their tolerance, regain their sensitivity, and keep their cannabis dose within the ideal range for their needs (and budget) by taking breaks from their treatments.

Does tolerance mean your patient has an addiction?

Developing a tolerance to a substance is often associated with chemical dependence and addiction, but tolerance is not necessarily synonymous with addiction. Tolerance can occur after normal prescription drug use, recreational drug use, and alcohol use. If tolerance occurs alongside more concerning signs like heavy use (i.e. beyond what is prescribed), risk-taking behaviours, and neglecting responsibilities, it could indicate a more serious problem like addiction. 

Medicinal cannabis is known to have a low to moderate risk of dependence that is significantly lower than alcohol, nicotine, caffeine, and prescription drugs like morphine and opioid medicines.⁵ 

Taking a tolerance break can reduce the amount of THC your patient needs to feel the therapeutic benefits of their medicine, and can help to reduce their risk of dependence. For most people, there is a low risk of withdrawal symptoms when taking a tolerance break. 

What happens to the body during a tolerance break?

Prolonged consumption of THC can result in the CNS decreasing its cannabinoid receptors in an attempt to try and rebalance itself. 

The constant activation of the ECS’s cannabinoid receptors by the THC can cause them to ‘downregulate’ and reduce their sensitivity to cannabis. This downregulation becomes cumulative when cannabis use is repeated before the cannabinoid receptors have fully upregulated after the last exposure to THC. 

When patients take a break from THC, they are allowing their cannabinoid receptors to adjust and balance themselves out chemically so that the patient can regain sensitivity to cannabis and achieve their desired therapeutic benefits without having to increase their dose and flood their cannabinoid receptors. 

What are the benefits of tolerance breaks?

Tolerance breaks can help patients get the most out of their medicinal cannabis treatments in a number of ways. If your patient has developed a tolerance to the effects of their treatment, they may find that they need to increase their dose of THC to higher levels to find relief from their symptoms. 

However, by doing this, patients can run the risk of overwhelming their endocannabinoid system. 

Phytocannabinoids – like those found in cannabis, including THC and CBD – interact with the ECS in varying ways. THC can activate specific cannabinoid receptors to produce a psychoactive effect, which may help to relieve pain, reduce nausea and vomiting, increase appetite, improve sleep and more. 

On the other hand, CBD interacts with opioid, dopamine, and serotonin receptors, giving it the potential to reduce pain, depression and anxiety while boosting the immune system and helping with addiction. Because THC works so directly upon the ECS and cannabinoid receptors, using too much can actually flood these receptors, potentially leading to dysregulation within the body and unwanted side effects in patients like insomnia, anxiety, and more.

If you notice a patient continually requests that you up their dose, you can help to ensure they do not overwhelm their ECS with THC by encouraging them to take a short-term break from their treatments. This will allow your patient to continue using THC to improve ECS function and assist with pain relief, sleep, anxiety and more, rather than creating dysfunction. 

If your patient is hesitant to take a tolerance break from their treatment, some additional benefits you may like to highlight for them include: 

• Longer lasting medication 
• Less money spent on treatments 
• Less scripts to fill 
• More benefits from their treatments over time 

How to identify when a patient needs a tolerance break 

If a patient approaches you with concerns that they are not getting the same results they usually would with their regular dose of medication, it may be time for a tolerance break. 

Depending on their symptoms and condition, some signs that may indicate your patient might need a tolerance break include: 

• They’ve stopped experiencing the same amount of pain relief 
• They have had to increase their dose 
• They’re more restless at night when their medication would usually be helping them sleep 
• An increase in their anxiety symptoms 
• More of their medication is needed to combat nausea 
• Running out of medication earlier than expected 

Whatever it looks like for your patient, their medication’s reduced effectiveness may be a result of a built-up tolerance to medicinal cannabis, and it’s a good time to encourage a tolerance break. 

It’s important you work with your patients to create a plan for their tolerance break, including when they should take the break, how long the break will be for, how they can manage their symptoms during that time instead, and how they can resume their THC treatment at the end of their tolerance break. 

How long should a tolerance break be?

There is no universal ideal timeframe for taking tolerance breaks, though it is generally accepted that a tolerance break should be at least 48 hours long to give the cannabinoid receptors enough time to start to reset. 

For long-time users who want a true reset and for THC to leave the system entirely, some patients take tolerance breaks ranging from a few weeks to a month to get back to optimal endocannabinoid system functioning. 

As with every treatment plan, the length of a tolerance break depends on each individual patient, their situation, and their goals.

How to support your patient after their tolerance break 

When a patient resumes their treatment at the end of their tolerance break, the prescribing doctor should provide the patient with a new starting dose that may be equivalent to half of the original dose. 

This enables you to work with your patient to titrate up slowly to find their new ideal dose. If the new dose is the same or even lower than the original dose and the patient is achieving their desired therapeutic results, then their tolerance break was likely effective. 

In some circumstances, you may find it beneficial to the patient to prescribe a new type of medicinal cannabis treatment with varying cannabinoid ratios and terpene blends for them to try at the end of your tolerance break. This can help the patient’s receptors kick back in to ensure they get the most out of their medicinal cannabis treatments.