The Effects of Cannabinoids on Sleep
Bhanu Prakash Kolla, Lisa Hayes, Chaun Cox, Lindy Eatwell, Mark Deyo-Svendsen , and Meghna P. Mansukhani
Journal of Primary Care & Community Health, 2022, Volume 13, 1–9.
Doi : 10.1177/21501319221081277
The use of cannabis products to help with sleep and various other medical conditions by the public has increased significantly in recent years. Withdrawal from cannabinoids can lead to sleep disturbance. Here, we describe a patient who developed significant insomnia leading to worsening anxiety, mood, and suicidal ideation in the setting of medical cannabis withdrawal, prompting presentation to the Emergency Department and inpatient admission. There is a limited evidence base for the use of cannabis products for sleep. We provide a comprehensive review evaluating the literature on the use of cannabis products on sleep, including an overview of cannabis and related psychoactive compounds, the current state of the law as it pertains to the prescribing and use of these substances, and potential side effects and drug interactions. We specifically discuss the impact of cannabis products on normal sleep and circadian sleep-wake rhythms, insomnia, excessive daytime sleepiness, sleep apnea, parasomnias, and restless legs syndrome. We also describe the effects of cannabis withdrawal on sleep and how this increases relapse to cannabis use. Most of the studies are observational but the few published randomized controlled trials are reviewed. Our comprehensive review of the effects of cannabis products on normal sleep and sleep disorders, relevant to primary care providers and other clinicians evaluating and treating patients who use these types of products, shows that cannabis products have minimal to no effects on sleep disorders and may have deleterious effects in some individuals. Further research examining the differential impact of the various types of cannabinoids that are currently available on each of these sleep disorders is required.
Keywords : cannabis, cannabidiol, sleep, insomnia, sleepiness, sleep apnea, restless legs syndrome, rapid eye movement, sleep behavior disorder, treatment
A 24-year-old married, employed, male presented to the Emergency Department (ED) with new-onset suicidal ideation in the context of worsening depression, anxiety, and significant sleep disturbance. His past medical history was significant for attention deficit hyperactivity disorder (ADHD) and posttraumatic stress disorder (PTSD). He was not on any psychotropic medications. He described using
medical cannabis which he had obtained from a qualified cannabis dispensary after meeting with an independent provider who certified that he met the qualifying conditions to treat his PTSD symptoms. These symptoms included insomnia, nightmares, and anxiety for over 3 months prior to obtaining medical cannabis. The symptoms had improved with the use of medical cannabis; however, due to the significant expense associated with obtaining medical cannabis, he discontinued its use 2 days prior to his presentation to the ED.
In the first 2 days of discontinuation of medical cannabis, the patient started noticing difficulties with sleep initiation and maintenance, which in turn adversely impacted his mood and anxiety symptoms. He then started experiencing suicidal thoughts and presented to the ED. He was admitted to a specialized mood disorder unit and began treatment with paroxetine. Cognitive behavioral therapy was utilized
to address both anxiety and insomnia-related symptoms, with good benefit. His suicidal ideation resolved, and he was discharged after 10 days with outpatient follow-up for ongoing therapy and medication management.
The use of cannabis products to help with insomnia and other sleep disorders is increasing while evidence supporting their use is limited. Further, withdrawal from cannabis is associated with significant sleep-related symptoms and these sleep disturbances increase the risk of relapse to cannabis
use. There are a few older reviews of studies assessing the effects of cannabis products on sleep.1-11 The objective of the current comprehensive review was to update previous reviews and describe the current literature evaluating the effects of cannabis products on normal sleep and sleep disorders, both during active use as well as during withdrawal. We aimed to discuss the effects of cannabis products on circadian sleep-wake rhythms as well as the evidence for their use in various sleep disorders.
For this comprehensive narrative review, a literature search was performed in Ovid Medline, Embase and Scopus using search terms “cannabis” and “sleep” from January 1, 1960 to July 1, 2021 for all English articles of any study design. A total 818 abstracts were reviewed by authors BK and MPM. Articles published in medical journals but not book chapters were reviewed. Studies of adult human subjects examining the effects of cannabis products on sleep included in this review are summarized in Table 1 (n = 20); review articles and editorials are excluded from this list. No funding was received for this work.
First, we provide an overview of cannabis and psychoactive compounds, the current state of the law as it pertains to the use of these compounds, and potential side effects and drug interactions. We then discuss the effects of cannabis on normal sleep, circadian sleep-wake rhythms, effects on sleep during withdrawal, and conversely, the effects of poor sleep on relapse to cannabis use. Finally, we discuss the
impact of cannabis products on sleep-related symptoms and disorders, specifically, insomnia, excessive daytime sleepiness, sleep apnea, parasomnias such as nightmares and rapid eye movement behavior disorder (RBD), and restless legs syndrome (RLS).
Overview of Cannabis and Related Products
Cannabis and psychoactive compounds. Cannabinol was the first compound to be extracted from the cannabis plant. In the 1960s, an Israeli researcher Professor Raphael Meacholeum isolated both cannabidiol (CBD) and Δ9- tetrahydrocannabidiol (THC) and demonstrated that THC was the psychoactive compound. There are over 500 different compounds in the cannabis plant. Phytocannabinoids account for over a hundred of these and include Δ9-THC, CBD, and cannabinol. The remainder are non-cannabinoids and include terpenes, phenolic compounds, and alkaloids.