Sleep can be considered the foundation to a healthier lifestyle. According to American Academy of Sleep Medicine, 30% of adults have symptoms of insomnia and 10% diagnosed are severe enough to cause daytime consequences. Cannabis has been an alternative for patients who prefer not to use standard conventional regimens due to side effects and tolerability.
On average, an adult should have 7-9 hours of sleep per night, while children and teens require even more to grow. Patients have many variables to optimize before looking toward pharmacotherapy. These range from minimizing electronic devices to choosing a correct mattress to adjusting the temperature of the bedroom. Prescription medications are often prescribed to help patients reach their standard 8 hours, however, many prescription medications come with side effects and can be problematic for the patient’s quality of life.
Insomnia can be caused from various reasons. Most patients can have anxiety during the day which then carries over into nighttime affecting their sleep. Since anxiety is 1 of the 23 qualifying conditions listed in Pennsylvania for medical cannabis use, many patients seek cannabinoid therapy to improve their sleep hygiene. When managing patients with sleep disturbances, it’s important to understand if the patient is having trouble falling asleep (sleep-onset insomnia) or staying asleep (sleep maintenance insomnia). This is important because it can possibly change the route of administration for the patient that is recommended by the pharmacist. Inhaled forms of cannabis bypass the liver and are readily available in the blood stream. This allows the medicine to work within minutes allowing the patient to easily fall asleep. However, these forms are quickly removed from the body in about 2 hours. Patients with sleep maintenance insomnia may still wake once the medicine is out of their system. In these cases, an oral form of ingestion, such as a solution, capsule or tablet, would be more appropriate. With oral ingestion the medication must work through the liver and in doing so, can last in the body for up to 8 hours. It is normally recommended patients take the oral form 1-2 hours before bedtime to allow the medication to be properly digested.
It is important to note that insomnia is not an approved qualifying condition to treat patients with cannabis, however, due to the side effects of many traditional therapies, patients self-medicate with cannabis to improve their sleep. Some studies report that cannabis, in acute doses, improves sleep onset and stage 4 sleep while others suggest THC reduces REM sleep. Still other data shows cannabis products can improve sleep for individuals suffering from pain with minimal side effects. There seems to be more of an indication to treat insomnia if patients suffer from other conditions.
One study looked at patients from a medical dispensary in California with insomnia issues in addition to PTSD. It was concluded those with high PTSD scores were more likely to use inhaled cannabis to improve sleep, and for coping reasons more generally, compared with those with low PTSD scores. The general data seems to trend in favor of cannabis helping patients with sleep onset. There are still many unknowns with cannabis use, but this is common for many medications. Long term effects still need to be studied with strong clinical trials consisting of a control and double blinding subjects and researchers.
It is interesting to note that although cannabis is not a FDA approved medicine for sleep, many prescription medications prescribed for sleep are also not indicted for sleep. FDA approval is based off clinical trials which study the medication and disease in a controlled environment. When medications are prescribed without FDA approval, it’s called “off-label” which gives providers the ability to prescribe these medications based on experience and personal judgment. For example, Gabapentin was designed to help patients suffering from neuropathy, however many providers use it to treat sleep. Trazadone is FDA approved for depression in adults, however, many still use the medication to improve sleep. Regardless of the choice of therapy, it is important to have a conversation with the patient and understand what their goals are in order to select a medicine they feel most comfortable with using.
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