Sleep is an incredibly important predictor of health: getting less than 6 hours of sleep on a continuous basis makes you 48% more likely to die of heart disease and 15% more likely to have a stroke1. Although scientists are still not really sure why sleep is so good for us, they’ve recently discovered that sleep is like a “dishwasher” for your brain. During sleep, cerebrospinal fluid flow in the brain increases dramatically, washing away waste products that build up in the brain during the day2. By cleaning out these potentially toxic chemicals, sleep helps to protect us from diseases like Alzheimer’s, which has been linked to sleep deprivation3. In fact, losing even one night of sleep has been found to increase levels of beta-amyloid, the protein that clumps together in the brain to form the characteristic brain lesions in Alzheimer’s disease 4.
Disordered sleep can take many forms. The term “sleep disorder” is used to describe any condition that affects sleep quality, timing, or duration, and affects a person’s ability to function properly while awake. There are over 100 sleep disorders that have been identified, the most well researched being insomnia, sleep apnea, narcolepsy, restless leg syndrome, parasomnias, and REM sleep behavior disorder5.
Most people who struggle to sleep well are never diagnosed with a specific disorder and try to manage it on their own. Both over the counter and prescription sleeping pills, such as Ambien, are widely used, and carry risks of side effects, tolerance, and dependency. Some of these risks are serious and include an increased incidence of dementia6. Natural remedies such as melatonin, valerian, lavender, tryptophan, and magnesium are also widely used as sleep aids.
Sleep and Cannabis
Another increasingly popular sleep aid is cannabis. Approximately 50% of long-term cannabis consumers report using cannabis as a sleep aid, while among medical cannabis patients, 48% report using it to help with insomnia7. Some people using cannabis to treat sleep issues are also using it to treat other conditions, such as pain or mental health problems including anxiety, depression, and post-traumatic stress disorder (PTSD).
A recent study looking at consumer purchases in Colorado suggested that people may prefer to substitute cannabis for over-the-counter sleep aids when it is available for recreational use. Market shares for sleep aids, which were increasing before recreational cannabis became available, showed a 236% decrease as cannabis dispensaries opened and cannabis sales increased. Interestingly, the over-the-counter aids that decreased were diphenhydramine and doxylamine-based medications rather than natural medications like melatonin8. This sort of evidence strongly suggests that people perceive cannabis as being an effective sleep aid, although when we look at the research measuring the effects of cannabis on sleep, it is clear that the story is more complex. Studies show that cannabis can have both positive and negative effects on sleep, depending on dose and frequency of use, as well the form of cannabis being used.
Research on the impact of cannabis on sleep really got underway in the 1970’s and included both subjective and objective studies using polysomnography, which records body functions like brain waves during sleep. This early research suggested that long-term use of cannabis negatively impacted sleep, although studies also found that cannabis, as the whole plant or as THC, could benefit sleep. More recent research has also yielded mixed results.
In order to try to make sense of these conflicting findings, let’s first consider some of the positive effects that have been observed. Medical cannabis users (both with and without sleep problems) report experiencing falling asleep faster after cannabis use9, and a survey of over 1,500 medical cannabis patients found that approximately 2/3 were able to reduce their use of pharmaceutical sleep medication with cannabis use10. More objectively, polysomnographic studies have measured brain changes that indicate better sleep quality such as an increase in slow wave sleep11,12. People suffering from medical conditions that are associated with sleep problems, including fibromyalgia13, obstructive sleep apnea14,15, and PTSD16,17 have also benefited from using cannabis in the form of oral THC and as the synthetic THC pharmaceuticals Dronabinol and Nabilone. The pharmaceutical cannabinoid medication Sativex, which provides THC and CBD at an almost 1:1 ratio, has also been found to benefit sleep18, although a recent review article suggested that while subjective improvements are reported, Sativex does not increase sleep duration19.
On the other hand, there are some clearly negative effects of cannabis use on sleep, mostly when used chronically. Tolerance develops to sleep-inducing effects and slow-wave sleep enhancement, and there may be a worsening of sleep efficiency when cannabis is used over a long period of time20. This may encourage people to use higher doses of cannabis, which can lead to problematic patterns of use and dependency. Heavy cannabis use is itself associated with sleep disturbances, which are a hallmark of cannabis withdrawal, which can cause vivid dreams, decreased total sleep time, sleep efficiency, and % REM sleep21. This can last for up to 45 days after cessation of cannabis use22, and disturbed sleep is reported by over 2/3 of adults trying to quit using cannabis3,24. It’s important to note, though, that heavy cannabis use is not the same as medical cannabis use, or even recreational cannabis use. So, while this research is important in terms of showing the hazards associated with prolonged, heavy use of cannabis, the vast majority of cannabis users are not using cannabis in this way.
How do we make sense of these differences, and what do they tell us about the effect of cannabis on sleep? First, it seems clear that dose and duration of use are important considerations. Long-term use at high doses is not advisable, as it can negatively affect sleep in two ways: (1) Causing problematic patterns of use because of habituation and dependency to its sleep-inducing effect, and (2) Resulting in sleep disturbances due to cannabis withdrawal upon cessation of use. Second, there may be specific populations, such as people suffering from pain and anxiety disorders, that may benefit from using cannabis to improve sleep. There is evidence supporting the use of cannabis in the treatment of both pain and anxiety disorders such as PTSD, and cannabis may improve sleep in these populations through direct effects on sleep quality, as well as indirect effects on other sleep disrupting symptoms such as pain.
When it comes to sleep, however, not all cannabis is the same. The studies just described all used some form of THC, which is the major psychoactive cannabinoid in the cannabis plant. More recently, research has been investigating whether other molecules from the cannabis plant might benefit sleep, with the cannabinoid CBD emerging as another potential sleep aid. Although whether CBD is sedating or alerting seems to depend on dose. A recent article reviewed the research on CBD’s wakefulness and sleep promoting effects and concluded that low to moderate doses are stimulating, while high doses are sedating. The authors state that the stimulating effects of CBD are seen at doses under 200mg, while doses over 300mg have the opposite effect7, although it should also be noted that the dose effects of CBD on sleep in humans have not been thoroughly investigated. It is also worth noting that much smaller doses of more bioavailable forms of CBD may induce sleep, as it’s been found that only about 6 to 24% of fat soluble CBD (the form that is almost always used in research studies) ends up in the bloodstream25. It may also be possible to greatly reduce the amount of CBD needed to induce sleep by combining it with THC in doses ranging from 2.5mg to 15mg of each18. CBD may additionally benefit sleep by reducing anxiety7,26, and it appears to help people with Parkinson’s Disease suffering from REM Sleep Behavior Disorder27.
In addition to THC and CBD, there are also other molecules in cannabis that may benefit sleep. These include terpenes such as myrcene, which has sedative and tranquilizing effects28, as well as linalool (also found in lavender oil), which also induces sedation29. The minor cannabinoid cannabinol (CBN) is widely being marketed as a sleep aid, usually with reference to a study from 1975 that found that CBN combined with THC resulted in significant drowsiness30. However, there is currently no high quality evidence to support this claim.
I recently described that many health care providers using cannabis-based medicine are taking a personalized approach, tailoring medical decisions, prescriptions, practices, and interventions to the individual. This may need to be taken even further when it comes to sleep. A recent article in Time Magazine described new research that is challenging the idea that when it comes to sleep, we all have the same needs31. It turns out that we all have different internal clocks, or circadian rhythms, which may even affect how we metabolize medicines. In addition to variation in circadian rhythms, there may also be variation in the response to THC. An early study in only three subjects found that in one subject, THC increased REM sleep at 300 ug/kg but in two others it decreased their REM sleep but increased their percentage of time spent in slow wave sleep32. This variability has not been widely explored in recent research. Although this is largely speculation, it may be that when it comes to using cannabis to improve sleep, individual differences could be an even more important consideration than for some other conditions. These differences would be difficult to account for using traditional research approaches.
There is strong subjective support for the use of cannabis to improve sleep, and research shows that the short-term use of cannabis may be helpful for various sleep disorders or disorders in which sleep is secondarily impaired, like pain and anxiety disorders. However, habitual and prolonged use of cannabis at higher doses may be disruptive. There is also support for the use of CBD as a sleep aid, at least at higher doses. This could be applied therapeutically such that lower doses of CBD, which may have a stimulating effect, could be used during the daytime to treat other conditions such as pain and anxiety, while higher doses could be used at night as a sleep aid. As with whole plant cannabis and THC, CBD may be particularly helpful when sleep is impaired due to other conditions, especially those related to anxiety. Individual variations in circadian rhythms and responses to cannabis suggest that a personalized approach to using cannabis to improve sleep might be important.
Dr. Genevieve Newton, DC, PhD has spent the past 19 years as a researcher and educator in the field of nutritional sciences. A series of personal health crises led her to discover the benefits of cannabinoids, and she soon found herself engrossed in studying the endocannabinoid system and therapeutic applications of cannabis/cannabinoids in mental health, pain, sleep, and neurological disorders. She has recently taken a position as the Scientific Director at Fringe, a new medical CBD and education company.
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