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Cannabis & Sleep
What to Know
Last Updated:  11.22.22

Key Benefits
Sleep disorders have been treated with cannabis throughout history. Currently, there’s growing evidence for  the effectiveness of cannabis in treating sleep-specific and sleep-related maladies such as insomnia, anxiety, depression, and chronic pain.[1,2]

What do the studies tell us? Each individual's sleep-relevant reactions can be different for both CBD and THC based products.[3,4] While low doses of CBD are stimulating, medium and high doses can offer heightened sensations of relaxation.[5,6] There is even early evidence that CBD may help individuals with Parkinson’s disease control deep-sleep behavior disorder.[7]

Additionally, THC can decrease the time it takes to fall asleep, though of course the specific effects of THC are often dose-dependent.[8,9] THC can be an effective sleep aid when the appropriate dose is adjusted for that particular individual. 

Recently, a study tested cannabis on patients with chronic insomnia. These patients saw significantly improved sleep patterns compared to placebo, felt more rested when they woke up, and overall fatigue, stress, and social functioning improved.[11]

It’s also worth noting that unlike cannabis, many common prescription sleep medications disrupt sleep architecture and affect the REM sleep pattern. Cannabis doesn't interfere with sleep cycles if used under proper guidance, which can help patients achieve higher quality sleep.

And there’s another potential benefit of using cannabis to improve sleep: If cannabis is consumed and dosed correctly, it often reduces or even replaces the need for stronger, more addictive medications like benzodiazepines, barbiturates, and other sedatives. (Note, however, that any reduction in the use of these drugs should be done only under the close supervision of a physician, since withdrawal from sedatives can be dangerous and even fatal.)

While the research so far is promising, it’s clear that further study is needed to better understand the effects of specific cannabinoids on sleep. Current research also points to the importance of examining the impact of cannabinoid ratios, dose, timing, and route of administration in future studies since these factors can all influence outcomes.

Key Risks
First, it’s important to know that cannabis products contain chemicals such as THC and CBD that can interact with prescription medications. Those interactions can be potentially dangerous, increase or decrease prescription medication efficacy, and might cause adverse events.[12, 13]

These medications include antibiotics such as Erythromycin, cardiac medications such as Diltiazem and Verapamil, seizures medications such as Clobazam, antiviral medications such as Ritonavir, and life-saving blood-thinning medications such as Warfarin. Potential medication interactions are just one reason an expert cannabis clinician should always provide cannabis care. 

The long-term use of THC has also been linked to a diminished circadian rhythm as well as daytime sleepiness, late sleep onset (particularly at high doses and over time), and psychological effects such as adverse mood alteration and memory impairment.[14, 15]

Cannabis can also cause reversible liver enzyme increases when combined with antiseizure drugs. In fact, the European Academy report found that cannabis use may lead to more frequent bronchitis if smoked on a regular basis.

Another concern is that cannabis can increase the heart rate and either raise or lower blood pressure. These effects may impact frail, older adults with balance issues, who may have an increased risk of dizziness and falling when using cannabis.18

And of course, anyone using THC/intoxicating cannabis products should refrain from driving, operating heavy machinery, or any other activities in which intoxication might pose a health or safety risk to themselves or others.

Who Should Avoid Using Cannabis For Sleep?
Adolescents, individuals with a history of psychotic, mood or anxiety disorders, women who are pregnant, or planning to be pregnant, and people with cardiovascular diseases should only consider cannabis care after an extensive clinical evaluation and consultation with a licensed cannabis clinician.[16]

How Cannabis Works to Improve Sleep
Cannabis can help to achieve better sleep by reducing nighttime cortisol, which the body produces when stressed.[2]

Additionally, both CBD and THC can be useful in treating several conditions which might be causing a sleep disorder in the first place, such as anxiety or chronic pain. And CBD has been shown to support sleep processes by interacting with natural adenosine pathways. 

THC has also been shown to be effective at reducing rumination, promoting positive memories and lowering the intensity of negative experiences. When appropriately used, THC has even been shown to change how we remember dreams and can help reduce the memory of traumatic events. This can of course be particularly beneficial for those living with PTSD.[18]

Finally, CBD and THC appear to be helpful in achieving restful sleep because of the way CBD and THC interact with the endocannabinoid system (which we’ll introduce in greater depth below). Notably, endocannabinoid messenger molecule levels appear to be cyclical and correlate with the time of day, which might contribute to cannabis's effectiveness in supporting sleep and wake cycles.[17]

About the Endocannabinoid System
What is the endocannabinoid system? It’s complex—and rarely taught in medical school. But it can be helpful to think of the endocannabinoid system as one of the body’s master regulators.

Briefly stated, it’s a neuroregulatory system that keeps physiologic functions in balance or homeostasis. It plays a crucial role in inflammation, immune response, pain detection, the sleep-wake cycle, mood, memory, appetite regulation, reproduction, and fertility. It consists of three major components: naturally produced chemicals (self-made endocannabinoids acting as transmitters), the receptors those endocannabinoids bind to (located on neurons, immune cells, etc.), and the enzymes which synthesize and degrade these components.

The human body uses two naturally derived signaling molecules called endocannabinoids: anandamide (aka the bliss molecule) and 2-arachidonoylglycerol (2-AG). Endocannabinoids are structurally similar to, but distinct from, the cannabinoids found in cannabis plants, though they act on the same receptors.

Cannabinoids derived from plants are usually referred to as phytocannabinoids. These plant-based cannabinoids consist of a wide variety of active cannabinoid molecules, with nearly 150 discovered to date. The best known molecules are tetrahydrocannabinol (THC), tetrahydrocannabinol acid (THCA), cannabidiol (CBD), cannabigerol (CBG), or cannabinol (CBN).

In addition to these 150 cannabinoids, the cannabis plant produces hundreds more organic compounds called terpenes and flavonoids. These unsaturated hydrocarbons may not activate the endocannabinoid receptors directly, but they modulate and fine-tune the functions of the activated receptors. This effect (of interaction with the receptors and molecules is known as the "entourage effect."

The second component of the endocannabinoid system is the cannabinoid receptor. The biological effects of cannabinoids are controlled by dozens of known cannabinoid receptors, the most relevant being receptors 1 and 2. Cannabinoid receptor 1 is primarily located in the brain, while cannabinoid receptor 2 is present exclusively in immune cells throughout the body. If an endocannabinoid binds to a cannabinoid receptor 1 in the brain, it may help to relieve pain. In contrast, an endocannabinoid that attaches to the cannabinoid receptor 2 in the immune system might help relieve symptoms of inflammation; it can tone down pro-inflammatory markers like cytokines and interleukin.[19]

The third component of the endocannabinoid system are enzymes, which synthesize and break down endocannabinoids. While many enzymes keep the endocannabinoid system balanced, the ones of therapeutic interest are the fatty acid amide hydrolase (FAAH) and the monoacylglycerol lipase (MAGL). The body's endocannabinoid response can be improved by modulating these enzymes for therapeutic purposes.[20] As a result, the endocannabinoid system keeps our body balanced, and cannabis can help support its natural function.

How Cannabis Care Should Work
As the evidence grows, it’s increasingly clear: An ongoing partnership with a clinician is essential in order to use cannabis safely and optimally in the treatment of sleep issues.[22-27]

An eo clinician or other expert cannabis clinician with a thorough understanding of your goals, medical record, current medications, and cannabis use history should be involved in formulating initial and ongoing product recommendations, doses, and times of use. 

Questions?
Schedule a free consult with an eo team member today. Or email us at members@eo.care.

The content on this page is for informational purposes. Do not attempt to self-diagnose or prescribe treatment based on the information provided. Always consult a physician before deciding on the treatment of a medical condition.

Sources

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  2. Piper, B.J., et al., Substitution of medical cannabis for pharmaceutical agents for pain, anxiety, and sleep. Journal of Psychopharmacology, 2017. 31(5): p. 569-575.
  3. Babson, K.A., J. Sottile, and D. Morabito, Cannabis, Cannabinoids, and Sleep: a Review of the Literature. Curr Psychiatry Rep, 2017. 19(4): p. 23.
  4. Cousens, K. and A. DiMascio, (-) Delta 9 THC as an hypnotic. An experimental study of three dose levels. Psychopharmacologia, 1973. 33(4): p. 355-64.
  5. Nicholson, A.N., et al., Effect of Delta-9-tetrahydrocannabinol and cannabidiol on nocturnal sleep and early-morning behavior in young adults. J Clin Psychopharmacol, 2004. 24(3): p. 305-13.
  6. Zuardi, A.W., Cannabidiol: from an inactive cannabinoid to a drug with wide spectrum of action. Braz J Psychiatry, 2008. 30(3): p. 271-80.
  7. Chagas, M.H., et al., Cannabidiol can improve complex sleep-related behaviours associated with rapid eye movement sleep behaviour disorder in Parkinson's disease patients: a case series. J Clin Pharm Ther, 2014. 39(5): p. 564-6.
  8. Vaughn, L.K., et al., Endocannabinoid signalling: has it got rhythm? Br J Pharmacol, 2010. 160(3): p. 530-43.
  9. Gorelick, D.A., et al., Tolerance to effects of high-dose oral δ9-tetrahydrocannabinol and plasma cannabinoid concentrations in male daily cannabis smokers. J Anal Toxicol, 2013. 37(1): p. 11-6.
  10. Kuhathasan, N., et al., The use of cannabinoids for sleep: A critical review on clinical trials. Exp Clin Psychopharmacol, 2019. 27(4): p. 383-401.
  11. Walsh, J.H., et al., Treating insomnia symptoms with medicinal cannabis: a randomized, crossover trial of the efficacy of a cannabinoid medicine compared with placebo. Sleep, 2021. 44(11).
  12. Arellano, A.L., et al., Neuropsychiatric and General Interactions of Natural and Synthetic Cannabinoids with Drugs of Abuse and Medicines. CNS Neurol Disord Drug Targets, 2017. 16(5): p. 554-566.
  13. Anderson, G.D. and L.N. Chan, Pharmacokinetic Drug Interactions with Tobacco, Cannabinoids and Smoking Cessation Products. Clin Pharmacokinet, 2016. 55(11): p. 1353-1368.
  14. Perron, R.R., R.L. Tyson, and G.R. Sutherland, Delta9 -tetrahydrocannabinol increases brain temperature and inverts circadian rhythms. Neuroreport, 2001. 12(17): p. 3791-4.
  15. Dzodzomenyo, S., et al., Urine toxicology screen in multiple sleep latency test: the correlation of positive tetrahydrocannabinol, drug negative patients, and narcolepsy. J Clin Sleep Med, 2015. 11(2): p. 93-9.
  16. Ebbert, J.O., E.L. Scharf, and R.T. Hurt, Medical Cannabis. Mayo Clin Proc, 2018. 93(12): p. 1842-1847.
  17. Silver, R.J., The Endocannabinoid System of Animals. Animals, 2019. 9(9): p. 686.
  18. Mock, E.D., et al., Discovery of a NAPE-PLD inhibitor that modulates emotional behavior in mice. Nature Chemical Biology, 2020. 16(6): p. 667-675.
  19. Kesner, A.J. and D.M. Lovinger, Cannabinoids, Endocannabinoids and Sleep. Front Mol Neurosci, 2020. 13: p. 125.
  20. Zou, S. and U. Kumar, Cannabinoid Receptors and the Endocannabinoid System: Signaling and Function in the Central Nervous System. Int J Mol Sci, 2018. 19(3).
  21. Basavarajappa, B.S., Critical enzymes involved in endocannabinoid metabolism. Protein Pept Lett, 2007. 14(3): p. 237-46.
  22. Saeed, O.B., B. Chavan, and Z.T. Haile, Association between e-cigarette use and depression in US adults. Journal of Addiction Medicine, 2020. 14(5): p. 393-400.
  23. Reed, M.K., et al., A Failure to Guide: Patient Experiences within a State-Run Cannabis Program in Pennsylvania, United States. Subst Use Misuse, 2022. 57(4): p. 516-521.
  24. Balu, A., et al., Medical Cannabis Certification Is Associated With Decreased Opiate Use in Patients With Chronic Pain: A Retrospective Cohort Study in Delaware. Cureus, 2021. 13(12): p. e20240.
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  27. Slawek, D., et al., Medical Cannabis for the Primary Care Physician. J Prim Care Community Health, 2019. 10: p. 2150132719884838.
  28. Balu A, Mishra D, Marcu J, Balu G. Medical Cannabis Certification Is Associated With Decreased Opiate Use in Patients With Chronic Pain: A Retrospective Cohort Study in Delaware. Cureus. Dec 2021;13(12):e20240. doi:10.7759/cureus.20240
  29. Ware MA, Wang T, Shapiro S, et al. Cannabis for the Management of Pain: Assessment of Safety Study (COMPASS). The Journal of Pain. 2015/12/01/ 2015;16(12):1233-1242. doi:https://doi.org/10.1016/j.jpain.2015.07.014
  30. Asselin A, Lamarre OB, Chamberland R, McNeil S-J, Demers E, Zongo A. A description of self-medication with cannabis among adults with legal access to cannabis in Quebec, Canada. Journal of Cannabis Research. 2022/05/26 2022;4(1):26. doi:10.1186/s42238-022-00135-y
  31. Slawek D, Meenrajan SR, Alois MR, Comstock Barker P, Estores IM, Cook R. Medical Cannabis for the Primary Care Physician. J Prim Care Community Health. Jan-Dec 2019;10:2150132719884838. doi:10.1177/2150132719884838
  32. The use of cannabis products may carry unique risks for those who  “self-medicate” without professional guidance and could worsen subjective symptoms. 26 {Omar Saeed} [J Addict Med]
  33. A lack of healthcare professional guidance can result in inadequate symptom relief and frustrating patient-reported outcomes after cannabis use as adjuvant therapy. 27 {Megan K Reed} [Subst Use Misuse]
  34. Among patients suffering from chronic pain, certification in medical cannabis is associated with a decrease in opiate use along with physician intervention. 28 {Alan Balu} [Cureus]
  35. Experts agree; a physician should handle treatment prescriptions and follow-ups to ensure safety.). 29{Mark A.Ware} [The Journal of Pain].
  36. Self-medicating with recreational cannabis is not a safe substitute for supervised care by a doctor or nurse practitioner. 30 {Antoine Asselin} [Journal of Cannabis Research]
  37. Health care providers should monitor for health consequences of medical cannabis use, while also considering how medical cannabis could affect other prescription medications. 31 {Deepika Slawek} [J Prim Care Community Health]

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