Medical Cannabis and Insomnia

Insomnia is a sleep disorder that is characterized by difficulty falling asleep, difficulty staying asleep, or both.

Symptoms of insomnia

  • Hard to get to sleep
  • Wake up during the night, trouble getting back to sleep
  • Wake up too early
  • Feel tired in the morning
  • Sleepy during the day
  • General tiredness
  • Irritability
  • Problems with concentration and/or memory

It is estimated that 30%-50% of the general population has some degree of insomnia, and around 10% has insomnia that lasts a month or longer (chronic insomnia).

Insomnia affects people of all ages, and insomnia is more common in women than men.  Stress is a common cause of short-term insomnia.  If short-term insomnia is not properly addressed, it can progress into chronic insomnia.

Types of insomnia

  • Primary insomnia – sleep problems unrelated to any other health condition or problem
  • Secondary insomnia – sleep problems due to an underlying cause (e.g., health condition, medication, substance use)

Conditions that can cause insomnia

  • Pain (all types)
  • Anxiety
  • Cancer
  • Chronic Fatigue Syndrome
  • Depression
  • GERD (gastroesophageal reflux disease; heartburn)
  • Asthma

After you have been diagnosed with insomnia by your health care provider, treatment focuses on finding and addressing the cause, if any.  Treatment of insomnia usually includes non-medical and pharmacologic approaches.  A combined approach often works best.


Conventional Pharmaceutical Medications

A number of over-the-counter (OTC) sleep medications are available.  Some OTC medications contain antihistamines [e.g., diphenhydramine (Benadryl)] that can make you sleepy.  Antihistamines, however, may reduce the quality of sleep and cause side effects such as dry mouth, blurred vision, and daytime sleepiness.  These side effects may be worse in the elderly.

Prescription sleeping pills are known as “sedative hypnotics.”  Sedative hypnotics include benzodiazepines, barbiturates, and hypnotics.

  • Benzodiazepines include anti-anxiety medications such as alprazolam (Xanax), diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium).  These drugs may be useful in the short-term, but all benzodiazepines are potentially addictive.
  • Barbiturates depress the central nervous system and cause sedation.  Among barbiturates are “long-acting” barbiturates such as phenobarbital (Solfoton) and “short-acting” barbiturates such as pentobarbital (Nembutal) and secobarbital (Seconal).  There are worries about potentially fatal overdose with barbiturates, and they may cause physical and psychological addiction.
  • Newer insomnia (hypnotic) medications include zolipidem (Ambien), eszopiclone (Lunesta), zaleplon (Sonata), and ramelteon (Rozerem).  These medications are reported to be non-habit forming and able to be used for extended periods.  In rare cases, severe allergic reactions may occur including facial swelling and unusual behavior such as driving or performing other activities while asleep.  Although less than the other categories, some patients still report a hangover feeling and daytime sleepiness.

For patients who have depression associated with insomnia, antidepressants may be utilized that have sedative effects, for example, trazodone (Desyrel), doxepin (Sinequan) or mirtazapine (Remeron).

Side effects of sleeping pills are often more severe in the elderly, including excessive drowsiness, impaired thinking, night wandering, agitation, and balance problems.

Death due to overdose is a concern with many sleeping pills.


Complementary and Alternative Medicine

Natural Strategies for Insomnia

  • Melatonin (a hormone that is part of the sleep-wake cycle)
  • L-Tryptophan (an amino acid, pre-serotonin)
  • Valerian Root (sedating)
  • Kava Kava (sedating and relaxing)
  • California Poppy (sedating and relaxing)
  • Passion Flower (relaxing)
  • Warm milk (contains tryptophan, positive psychological effect)

Alternative Therapies

  • Homeopathy
  • Cortisol reduction
  • Biofeedback
  • Relaxation Therapy
  • Meditation
  • Acupuncture
  • Hypnosis
  • Sleep induction guided tapes/CDs


Medical Cannabis

Many patients also report that medical cannabis is quite effective in relieving their symptoms of insomnia.  Patients commonly say that medical cannabis provides relief of their insomnia better than pharmaceutical medications with significantly fewer side effects.  Medical cannabis may also be effective in treating associated symptoms of anxiety, depression, and pain.

Medical cannabis patients sometimes report that they have fewer dreams.  This effect may be particularly beneficial when using medical cannabis in the treatment of conditions such as Post-Traumatic Stress Disorder (PTSD).

Scientifically, there is basis for the use of cannabis in the treatment of insomnia and other sleep disorders.  One of cannabis’ key medicinal ingredients, tetrahydrocannabinol (THC), and the CB1 cannabinoid receptor have been shown to have sleep-inducing effects.  Another important cannabinoid, cannabidiol (CBD), has been shown to induce alertness and reduce non-REM and REM sleep.  These results demonstrate how the body’s endocannabinoid system likely plays an important role in sleep regulation, along with other diverse neurobiological functions such as learning, memory, feeding, and pain perception.

From a practical perspective, the opposing actions of THC and CBD with respect to sleep underscore the importance of using medical cannabis in consultation with a cannabinoid medicine specialist, as well as using the correct strain of medical cannabis that has been tested for its key cannabinoid components.


Highlights from the Scientific Literature

Murillo-Rodriguez E. (2008).  The role of the CB1 receptor in the regulation of sleep.

  • Conclusion: Experimental evidence shows that the administration of Delta9-THC promotes sleep.
  • Conclusion: The activation of the CB1 receptor leads to an induction of sleep, and this effect is blocked by a selective antagonist.

Murillo-Rodriguez E, et al. (1988).  Cannabidiol, a constituent of Cannabis sativa, modulates sleep in rats.

  • Conclusion: CBD modulates waking via activation of neurons in the hypothalamus and dorsal raphe nucleus (DRD).  Both regions are apparently involved in the generation of alertness.
  • Conclusion: Since CBD induces alertness, it might be of therapeutic value in sleep disorders such as excessive somnolence.

Hsiao YT, et al. (2012).  Effect of cannabidiol on sleep disruption induced by the repeated combination tests consisting of open field and elevated plus-maze in rats.

  • Conclusions:  CBD (cannabidiol), a psycho-inactive component of cannabis that has been shown to reduce physiologic non-REM (NREM) sleep and REM sleep in normal rats, may block anxiety-induced REM sleep alteration via its anxiolytic effect, rather than via sleep regulation, per se.


Medical Marijuana Patient Information

Besides smoking, delivery methods for the use of medical cannabis include vaporization, tinctures, teas, and edible products.  Edible cannabis products generally have the longest duration of action (up to 6-8 hours) and may be useful in achieving a full night’s sleep.  Proper strain selection (cannabinoid composition) is an important consideration in using medical cannabis to treat insomnia.

The most commonly reported side effects from the use of medical cannabis include dry mouth, red eyes, increased appetite, and tiredness (a beneficial effect in the treatment of insomnia).   There has never been a death attributable to a medical cannabis overdose.  Medical cannabis should be used in consultation with a physician who specializes in cannabinoid medicine.


Tips for getting a Good Night’s Sleep

  • Go to bed and get up on a regular schedule
  • Establish a relaxing routine before bed
  • Sleep in a dark, quiet, and comfortable room
  • Limit use of your bedroom to sleep and sex
  • Finish eating 2-3 hours before bed
  • Avoid caffeine within 6 hours of bedtime
  • Avoid alcohol within 2 hours of bedtime (no more than 1-2 drinks)
  • Avoid tobacco within 2 hours of bedtime (quitting tobacco completely would be better)
  • Exercise regularly, but not right before bed
  • Avoid naps
  • If you can’t fall asleep within 10-15 minutes, go to another room to read a book or watch TV until sleepy

References and Resources

Hsiao YT, et al. (2012). Effect of cannabidiol on sleep disruption induced by the repeated combination tests consisting of open field and elevated plus-maze in rats. Neuropharmacology. 2012;62(1):373-384. http://www.ncbi.nlm.nih.gov/pubmed/21867717

Mayo Clinic. Health Information. Insomnia.  http://www.mayoclinic.com/health/insomnia/DS00187

Murillo-Rodriguez E. (2008).  The role of the CB1 receptor in the regulation of sleep.  Progress in Neuropsychopharmacology & Biological Psychiatry. 2008;32(6):1420-1427. http://www.ncbi.nlm.nih.gov/pubmed/18514375

Murillo-Rodriguez E, et al. (1988). Cannabidiol, a constituent of Cannabis sativa, modulates sleep in rats. FEBS Letters. 2006;580(18):4337-4345. http://www.ncbi.nlm.nih.gov/pubmed/16844117

National Sleep Foundation.  http://www.sleepfoundation.org/

Project CBD.  http://projectcbd.com/ 

WebMD. Sleep Disorders Health Center.  http://www.webmd.com/sleep-disorders/insomnia-directory 

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About markrabe

Mark L. Rabe, MD, ABIHM Integrative Holistic Medicine Centric Wellness 2308 6th Avenue San Diego, CA 92101 Telephone: (619) 546-0420 Fax: (619) 615-2346 E-Mail: info@CentricWellness.com

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