Sleep Disorders and Cannabis

Sleep is essential for good health. Not getting enough uninterrupted sleep negatively affects a person’s attention, learning and memory, and physical health.

About 50 to 70 million Americans have sleep or wakefulness disorders. Sleep deficiency and untreated sleep disorders are associated with a growing number of health problems, including heart disease, high blood pressure, stroke, diabetes, obesity, and certain cancers. Sleep disorders can also be costly. Each year sleep disorders, sleep deprivation, and sleepiness add to the national health care bill. Undiagnosed sleep apnea alone is estimated to cost the Nation $150 billion annually. Additional costs to society for related health problems, lost worker productivity, and accidents make sleep disorders a serious public health concern. — National Heart, Lung, and Blood Institute (1)

Learn more about Cannabis and Sleep below.

We all have them, some more than others and for different reasons...sleepless nights. Two major sleep disorders affecting millions are insomnia and sleep apnea. An Australian study showed the financial and nonfinancial costs associated with inadequate sleep are substantial. The estimated total financial cost of $17.88 billion represents 1.55 per cent of Australian gross domestic product. The estimated non-financial cost of $27.33 billion represents 4.6 percent of the total Australian burden of disease for the 2016 - 2017 year. (17)

Insomnia

Insomnia can present itself in a couple of forms, short-term and acute or chronic insomnia. Acute episodes are common and situational, brought on by stress; work, family or a traumatic experience can cause acute and short term sleeping problems. Acute insomnia lasts for days or weeks, while chronic insomnia lasts for a month or longer. Most cases of chronic insomnia are secondary, which means they are the symptom or side effect of some other problem. Certain medical conditions, medicines, sleep disorders, and substances can cause secondary insomnia. In contrast, primary insomnia isn t due to medical problems, medicines, or other substances. It is its own distinct disorder, and its cause isn't well understood. Many life changes can trigger primary insomnia, including Post Traumatic Stress Disorder (PTSD) which presents long-lasting stress and emotional upset. Insomnia can cause daytime sleepiness and a lack of energy. It also can make you feel anxious, depressed, or irritable. You may have trouble focusing on tasks, paying attention, learning, and remembering. These problems can prevent you from doing your best at work or school. (2)

Currently, three classes of medications have FDA approval for treating sleep disorders: benzodiazepines, barbiturates and non-benzodiazipine hypnotic medications. (1) All have significant adverse side effects, including dependence, serious withdrawal, and complex sleep-related behaviors. Adverse Effects OF Benzodiazepines such as Xanax include physical dependence and withdrawal, and irritability. Newer hypnotics such as Ambien and Lunesta can cause complex sleep-related behaviors. (1) If you have not heard any crazy Ambien stories on the news, Reddit provides an eye-opening encapsulation of scary testimonials.

Research points to a role for the Endocannabinoid System (ECS) in regulating the sleep cycle. By affecting the rhythm of the adenosine pathway, the ECS likely plays a role in helping the system reach a threshold level that allows the sleep cycle to begin. (4, 7) The Endogenous Cannabinoid Anandamide, which acts on the same receptors as THC, has been shown to increase sleep through an adenosine pathway in the rat basal forebrain. (4, 8) Exogenous Phytocannabinoids such as THC and CBD may override dysregulation of this system by resetting the threshold level of adenosine. Furthermore, CBD appears to have a modulating effect on the Endocannabinoid System through inhibition of anandamide hydrolysis and may allow for a wider clinical window with less of the side effects associated with THC. (4, 9)

Scientists have discovered that light is as essential to optimal health and development as vitamins and exercise. In nature, the sun delivers the entire spectrum of light needed by your eyes and brain to align daytime with being awake and nighttime with preparing for sleep. (3) Dr. Michele Ross, PhD, author of Vitamin Weed: A 4-Step Plan to Prevent and Reverse Endocannabinoid Deficiency calls vitamin D a little miracle vitamin, (which helps support CB2 receptor function). The Federal Government has stated we get enough vitamin D from our food and sunlight. The state of our fast-food culture and avoidance of direct sunlight with use of UV blocking sunscreens could be causing some to be Endocannabinoid Deficient, a theory developed by Dr. Ethan Russo. (18) A global epidemic, up to 50% of humans are deficient in vitamin D with a higher incidence rate in chronically ill patients. Vitamin D deficiency has been linked to multiple sclerosis, migraines, depression, weight gain, cancer, Crohn's disease and ulcerative colitis. (12, 13, 14, 15)Should we add insomnia to Dr. Ross' list?

Cannabis and Insomnia

We like studies published in O Shaughnessy s because it is the publication that re-introduced Cannabis to the West in 1839. (4) A researcher in Southern California analyzed data previously collected from a cohort of 166 patients in a Cannabis-oriented practice run by another Doctor. The sample was blindly selected from files designed to provide a broad spectrum over three years of patient visits. In the cohort there were two groups, patients reporting trouble sleeping and patients that did not report sleep troubles. (4)

Both those with sleep difficulties and those without reported a significant decrease in time to sleep after the use of Cannabis. The significant difference between those patients reporting insomnia and those who did not indicates that there are various levels of insomnia severity. As a median, it took 30 minutes less time for patients to fall asleep, even if they didn t report sleep troubles. Those with sleep troubles, as a median spent 15 minutes less time falling asleep. By validating patients historic reporting of better sleep with a quantifiable difference, this data supports the use of Cannabis-based medicine for the treatment of insomnia, especially insomnia with resistant or contraindications to traditional methods of treatment. (4)

Exogenous Phytocannabinoids such as THC and CBD may override dysregulation of the adenosine pathway by resetting the threshold level of adenosine. Furthermore, CBD appears to have a modulating effect on the Endocannabinoid System through inhibition of anandamide hydrolysis and may allow for a wider clinical window with less of the side effects associated with THC. (9) The use of nighttime Cannabis for PTSD patients with significant nighttime sleep disturbances may be a future direction of research. Clinicians can utilize THC/CBD reduction of the duration of Rapid Eye Movement sleep (REM sleep), a time which appears to be a source of trauma and disrupted sleep for patients with frequent nightmares or disturbing dreams, for therapeutic effect. (4, 10, 11)

Cannabis and Post Traumatic Stress Disorder

There is a lot of anecdotal evidence that Cannabidiol assists patients with sleep disorders caused by PTSD. A 2016 case report demonstrates CBD's ability to provide some relief to a young girl, a victim of sexual assault. She presented in January 2015 for a re-evaluation of behaviors related to her diagnosis of Post Traumatic Stress Disorder secondary to sexual abuse. Her chief issues included anxiety, insomnia, outbursts at school, suicidal ideation, and self-destructive behaviors. (16)

It is reported the patient was receiving no pharmaceutical medications, other than a non-prescription diphenhydramine (antihistamine), and nutritional supplements and the CBD oil to control her symptoms. Her scores on the sleep scale and the anxiety scale consistently and steadily decreased during a period of 5 months. She was ultimately able to sleep through the night most nights in her own room, was less anxious at school and home, and displayed appropriate behaviors. The patient s grandmother (her caregiver) reported: My granddaughter s behaviors are definitely better being on the CBD. Her anxiety is not gone, but it is not as intense and she is much easier to be around. She now sleeps in her own room most of the time, which has never happened before. (16)

Sleep Apnea

Sleep apnea is a common sleep disorder characterized by brief interruptions of breathing during sleep. These episodes usually last 10 seconds or more and occur repeatedly throughout the night. People with sleep apnea will partially awaken as they struggle to breathe, but in the morning they will not be aware of the disturbances in their sleep. The most common type of sleep apnea is obstructive sleep apnea, caused by relaxation of soft tissue in the back of the throat that blocks the passage of air. Central sleep apnea (CSA) is caused by irregularities in the brain s normal signals to breathe. Most people with sleep apnea will have a combination of both types. The hallmark symptom of the disorder is excessive daytime sleepiness. Additional symptoms of sleep apnea include restless sleep, loud snoring (with periods of silence followed by gasps), falling asleep during the day, morning headaches, trouble concentrating, irritability, forgetfulness, mood or behavior changes, anxiety, and depression. Not everyone who has these symptoms will have sleep apnea, but it is recommended that people who are experiencing even a few of these symptoms visit their doctor for evaluation. Sleep apnea is more likely to occur in men than women, and in people who are overweight or obese. (19)

Cannabis and Sleep Apnea

Serotonin, acting in the peripheral nervous system, can exacerbate sleep-related apnea, and systemically administered serotonin antagonists reduce sleep-disordered respiration in rats and bulldogs. Because Cannabinoid receptor agonists are known to inhibit the excitatory effects of serotonin on nodose ganglion cells, we examined the effects of endogenous (oleamide) and exogenous (delta9-tetrahydrocannabinol; delta-9-THC) cannabimimetic agents on sleep-related apnea. (20) Limited research suggests potent suppression of sleep-related apnea by both exogenous and Endogenous Cannabinoids. Synthetic THC has demonstrated it suppresses 5-HT-(receptor)-induced reflex apnea, and increases phasic, but not tonic, activation of the genioglossus. This data supports the view that dronabinol stabilizes respiratory pattern and augments upper airway muscles by acting at the nodose ganglia. (20, 21)

Elderly

Changes in sleep patterns and quality of sleep are considered a natural part of aging. Poor sleep quality is often associated with impairment in quality of life, yet its effect on the elderly s health is much greater. Difficulty maintaining sleep has been found to correspond with a more pronounced cognitive decline in elderly patients with normal cognition. (22, 24) Moreover, it was found short sleepers with poor quality of sleep were found to have a 63% higher risk of cardiovascular disease. (22, 25) Mentioned above, the current treatment options include benzodiazepines, nonbenzodiazepines and melatonin supplement, which may subject patients to various adverse effects, some endangering their health. (22)

Senior citizens are trying Cannabis in greater numbers nowadays. In once conservative Orange County, California a monthly bus transports seniors from a living community in Laguna Niguel to a dispensary for a day of education, fun and shopping. Cannabis among adults 50 and older increased significantly; 50 to 64 year old rose from 4.5 to 7.1 percent, while 65 and older rose from .4 to 1.4 percent. They increased 58 and 250%, respectively from 2006 to 2013 (26) and believe even more so today.

Cannabis and the Elderly

Research exploring the influence of Cannabis on sleep suffers from low grade evidence and conflicting data. Based on these data a recent meta-analysis concluded that non-medicinal use of Cannabis may cause reduced slow-wave sleep and resultant increased phase 2 time. In contrast, the medicinal use of Cannabis appears to reduce sleep disturbances and improve sleep quality without affecting sleep duration. (22, 23) Specific indications of sleeping problems include:

Rapid Eye Movement sleep behavior disorder (RBD): CBD appears to be a prospective line of treatment in patients suffering from both Parkinson's disease and Rapid Eye Movement sleep disorder. In a case series of four patients suffering from Parkinson's disease and RBD, CBD treatment led to a remarkable reduction in frequency of symptoms. (22, 27)

Night-time agitation: a small study of six patients suffering from severe dementia (five with AD and one with vascular dementia) and exhibiting night-time agitation showed that THC led to a significant reduction in nocturnal motor activity as well as an improvement in the Neuropsychiatric Inventory Total Score following treatment. (22, 28)

Some considerations need to be discussed for new elderly patients and the intoxicating side-effects of THC. It has been reported that side-effects are begin to be felt at doses as low as 2 - 3 mg. Possible symptoms of the side-effects particularly concerning for elderly patients is light-headedness, dizziness and unstable gate when getting up from the bed. Adding chamomile to the Cannabis intake could help alleviate some of these effects of intoxication, good options are a tea or sublingual extract. Another way to mitigate intoxicating side-effects of THC is to increase the amount of CBD; patients report a ratio of 4:1 CBD:THC is where THC's intoxicating side-effects are not.

Shift Work Disorder

Shift work sleep disorder (SWSD) is a sleep disorder that commonly affects those who work non-traditional hours, outside the typical 9 a.m. to 5 p.m. work day. Shift work schedules go against most peoples’ internal body clocks or circadian rhythms. SWSD causes difficulties adjusting to a different sleep/wake schedule, which results in significant issues with falling asleep, staying asleep, and sleeping when desired. About 20% of the full time workforce in the US is involved in some form of shift work. (37)

The most common symptoms of SWSD are difficulty sleeping and excessive sleepiness. Other symptoms associated with SWSD can include difficulty concentrating, headaches, or lack of energy.

Not every shift worker suffers from shift work sleep disorder. It is estimated that 10% to 40% of shift workers have SWSD. (37)

A study by Occupational and Environmental Medicine found that about 12% of work injuries experienced by women and 6% of work injuries experienced by men were attributed to the higher risk of work injury during evening, night and early morning hours. (38) This population is also almost twice as likely to use illicit drugs as individuals working a standard day shift. (39)

Cannabis and Shift Work Sleep Disorder

A very small study followed ten experienced Cannabis smokers who completed this 23 day, within-participant residential study. They smoked a single Marijuana cigarette (0, 1.9, 3.56% Δ9-THC) one hour after waking for three consecutive days under two shift conditions: day shift and night shift. Shifts alternated three times during the study, and shift conditions were separated by an 'off' day. When participants smoked placebo cigarettes, psychomotor performance and subjective-effect ratings were altered during the night shift compared to the day shift: performance (e.g., vigilance) and a few subjective ratings were decreased (e.g., "Self-Confident"), whereas other ratings were increased (e.g., "Tired"). Objective and subjective measures of sleep were also disrupted, but to a lesser extent. Marijuana attenuated some performance, mood, and sleep disruptions: participants performed better on vigilance tasks, reported being less miserable and tired and sleep a greater number of minutes. Limited negative effects of marijuana were noted. These data points demonstrate that abrupt shift changes produce performance, mood, and sleep decrements during night shift work and that smoked Marijuana containing low to moderate Δ9-THC concentrations can offset some of these effects in frequent Marijuana smokers. (39)

Cannabinol (CBN), Another Cannabinoid for Sleep

THC and CBD have been talked about yet there is another Cannabinoid that helps with sleep. CBN, short for Cannabinol, is a chemical naturally found in the aged Cannabis plant. THC and CBD molecules naturally breakdown to CBN, as the flower ages with exposure to UV light and air. Cannabis flowers that have been cured for longer periods of time will naturally have higher levels of CBN than plants that were recently harvested. Also, Cannabis plants grown outdoors in sunlight will have a higher level of CBN, compared to a plant grown indoors. Unlike THC, CBN does not cause intoxication.

CBN and Sleep

Of all the Cannabinoids, CBN appears to be the most sedative. Not only is it sedative, it takes very little to do the job. The consumption of 2.5 mg to 5 mg of CBN has the same level of sedation as a mild pharmaceutical sedative, with a relaxed body sensation similar to 5 mg to 10 mg of diazepam. CBN is synergistic with both CBD and D9THC for inducement of sleeping, and when mixed in the correct ratios, CBN becomes an effective sleep aid of 5 - 6 hours duration. CBN appears to be a beneficial alternative to THC for treatment, and patients that require low (or no) adverse psychoactive effects. (36)

Activate Your Cannabis for More CBN Potential

CBN is produced when the THC and CBD chemical compounds decay. Raw Cannabis flowers contain the acidic forms of the molecules and lose the Carboxylic Acid group (COOH) when heat is applied or through natural decay; THCA converts to THC and CBDA converts to CBD after activation, a process call decarboxylation. Ardent Cannabis Nova Precision Decarboxylator patients with PTSD and insomnia have reported relief of symptoms by smoking or vaping previously activated Marijuana. Smoking decarboxylated medicine produces more CBN creating powerful a sedative effect. Research suggests that CBN coupled with THC produces sedation. Ardent Cannabis patient @svenskasmokes smokes decarbed flower before bed for a restful sleep. Noting that she gets up at least once a night to use the restroom says, “I smoke a bowl before bed and as long as I am not up too long while using the restroom, I can fall back to sleep. If I was smoking raw flower, I would need to smoke each time I got up in the middle of the night to use the restroom.”

Endocannabinoid Deficiency Theory

We all possess an underlying Endocannabinoid tone that reflects of levels of anandamide (AEA) and 2- arachidonoylglycerol (2-AG), the centrally acting Endocannabinoids, their synthesis, catabolism, and the relative density of Cannabinoid receptors in the brain. If Endocannabinoid function were decreased, it follows that a lowered pain threshold would be operative, along with derangements of digestion, mood, and sleep among the almost universal physiological systems subserved by the Endocannabinoid System (ECS). The CED theory also posits that such deficiencies could arise due to genetic or congenital reasons or be acquired due to intercurrent injury or disease that consequently produces characteristic pathophysiological syndromes with particular symptomatology. (18)

Cannabis, by enhancing Endocannabinoid tone and adjusting neurotransmission rates, promotes homeostasis within the body. Another factor to consider may be concentration of THC, whereby lower levels induce sleep and higher levels cause increased dopaminergic activity. THC:CBD ratio may be equally significant. (4) Everyone's ECS is unique to them, leading to patients having to experiment some to find what works best for them. Below, is a link to a patient journal.

Potential Drug Interactions

CBD is metabolized via the cytochrome P450 system (29), mainly by isozymes located in the liver (30). Most drug interactions are associated with concurrent use of other Central Nervous System depressants with Cannabis. In clinical research, drug interactions are rare and there is no drug that cannot be used with Cannabis, if necessary. Existing studies have not demonstrated toxicity/loss of effect of comitant medications, but still theoretically possible. (31, 32, 33)

If you are taking a medication that says "Do Not Take With Grapefruit", taking CBD in tincture, pill capsule or edible form could cause you to have too much of your medication in your bloodstream. This could cause unwanted side effects. This can happen with common drugs including warfarin, taken by millions for blood clots, and antidepressants like Zoloft. (34) Dr. Michele Ross, PhD writes in her book, Vitamin Weed: A 4-Step Plan to Prevent and Reverse Endocannabinoid Deficiency, ways to mediate the risk include lowering your dose of medication under your doctor's guidance or lowering your dose of CBD to a dose that causes minimal inhibition of P450 enzymes.

If you take prescription medicines for blood pressure or central nervous system or are a sensitive patient, we recommend consulting a Medical Cannabis Practitioner (Canna-Nurse). CBD can lower blood pressure (35) precaution must be taken. My father, who was battling Stage 4 Renal Cell Carcinoma, had a blood pressure event when I switched his Full Extract Cannabis Oil (FECO), also referred to as Rick Simpson Oil (RSO), to a CBD dominant strain.

Your Cannabis Journey

Your Endocannabinoid System is unique to you and so will your Cannabis experience. If you feel a consultation with an expert is warranted, we recommend Green Health Solutions for over-the-phone consults.

Journaling your Cannabis journey will allow you to stay more connected and focused on your health. It also allows you to notice nuances, small changes in your condition, that you might not have otherwise noticed on a day-to-day basis. Everyone's Endocannabinoid System is unique and a journal helps pin-point what worked or is working or what is not doing the trick. Here is a journal template for you to download and use, Medical Cannabis Journal Template.

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