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Medicinal Cannabis and Insomnia

Struggling to get to sleep, waking up in the middle of the night or anxiously watching the clock are all common features of insomnia, an inability to initiate or maintain sleep, or a lack of refreshing sleep. An estimated 30% of the population experience disrupted sleep, and 10% have associated symptoms of daytime impairment[1]. Although insomnia is the most common sleep complaint, it is only rarely a primary condition, but more commonly a symptom of something else.

Psychological concerns, including stress, anxiety, and depression, are the root cause of more than half of all cases of insomnia. Other contributing factors can include medications, medical conditions, and organic disorders such as sleep apnoea or episodic movement disorders[2]. Importantly however, insomnia can occur in anyone, including healthy people. The current unprecedented global climate can trigger insomnia even in those who were previously good sleepers. Essential workers experiencing pandemic related trauma, and those working extended hours are at high risk of stress related insomnia. For most of us, short-term insomnia will improve when stress is resolved. For some however, insomnia can become chronic, generally if the duration is greater than 30 days1.

The first step to tackle insomnia is to practice good sleep hygiene. Sticking to a regular sleep pattern, making your bedroom quiet, dark, and cool, and practicing relaxation techniques can all help. Things to avoid include napping during the day, caffeine, and screen time in the hours before bed, and common vices to combat fatigue like sugar and snacking[3]. When there is no obvious underlying cause for insomnia, or the primary cause cannot be resolved, some people may be prescribed medications to help with sleep. Traditional pharmacological treatment can include hypnotic drugs (a benzodiazepine, zolpidem or zopiclone), which may be indicated for short-term management of acute insomnia, or for chronic insomnia when non-drug strategies are not effective[1].

Traditional hypnotic drugs have some limitations and potential problems, including the risk of impaired daytime alertness, tolerance, and dependence with long-term use. Continuous treatment with hypnotic drugs is typically limited to less than 2 weeks, to avoid a phenomenon known as rebound insomnia. Broken sleep and vivid dreams can occur when hypnotics are stopped, and it can take several days or weeks for a normal sleep rhythm to be re-established. When taking hypnotics, many people find sleep is not refreshing, and complex sleep-related behaviours such as paradoxical reactions (hallucinations, acute rage, agitation) can occur[2].

If the above first-line treatments are not tolerated, effective or suitable, some patients may consider cannabis for insomnia in partnership with their medical practitioner. Cannabis plant is a combination of hundreds of active compounds, including the primary phytocannabinoids THC and CBD, minor phytocannabinoids, terpenoids, flavonoids and carotenoids.

Scientific investigation has identified THC as the major player in promoting sleep and restfulness. Multiple unique actions, including direct interaction with receptors in the brain, and potentiation of the body’s own natural sleep enhancing compounds, create its therapeutic efficacy. THC in isolation however can cause anxiety and agitation in some people. Another primary cannabinoid, CBD, has been shown to counter the incidence of these adverse effects, and a synergistic effect is created when taken together. In addition to these major cannabinoids, other components of cannabis plant, including minor cannabinoids such as CBN, and terpenes like linalool, all have demonstrated sedative and relaxing activity. This balanced action of multiple components of cannabis has been termed the entourage effect and suggests that a full-spectrum whole plant extract may be therapeutically superior to isolated compounds[3].

Clinical research has demonstrated cannabis can improve insomnia, restfulness, and sleep quality. Generally medicinal cannabis is well tolerated, and unlike typical hypnotic drugs, does not create tolerance, dependence, and is not toxic in overdose. CBD can interact with some medications, and a thorough medication history should always be taken when considering any cannabis treatment.

Medicinal cannabis is available as a treatment option to eligible patients in Australia and can be prescribed where appropriate under the guidance of a medical practitioner.

If you are experiencing insomnia, or symptoms of anxiety, speak with your doctor and seek support. More tips and advice are available free online from BeyondBlue, Headspace and Head to Health.

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[1] Therapeutic Guidelines. eTG complete [digital]. Melbourne: Therapeutic Guidelines Limited; 2019 Jun. Sourced at: tg.org.au, May 2020

[2] National Institutes of Health State of the Science Conference statement on manifestations and management of chronic insomnia in adults, June 13–15, 2005. Sleep. 2005;28(9):1049–57

[3] Siebern A, et al. Non-pharmacological treatment of insomnia. Neurotherapeutics. 2012;9(4):717–27

[4] Schutte-Rodin S, et al. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;4(5):487–504

[5] National Institute for Clinical Excellence (NICE). Guidance on the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia (TA77). London: NICE; 2004

[6] Russo E. The case for the entourage effect and conventional breeding of clinical cannabis: no ‘strain’, no gain. Front. Plant Sci 2019(9): 1969

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