Is cannabis exacerbating the sleep crisis?

Legal cannabis may be making this sleep-starved country even groggier.

With 35% of US adults saying they get less than 7 hours of shut-eye nightly, increasing numbers are turning to legal weed as a way to get to sleep faster, manage other sleep disorders, or mitigate the symptoms of disease.

But not so fast, says one sleep expert. When it comes to sleep, patients who use cannabis might be doing more harm than good.

Bhanuprakash Kolla, MD, a Mayo Clinic psychiatrist who specializes in sleep medicine and addiction, says that even though at least one state, Minnesota, has approved medicinal cannabis for obstructive sleep apnea (OSA), the American Academy of Sleep Medicine (AASM) does not recommend cannabis for sleep disorders.

How cannabis affects sleep

With scant comprehensive research available about the effects of cannabis on sleep, as well as poor quality control of the drug, Dr. Kolla says that he and other sleep physicians have doubts about the safety of the drug for sleep disorders, including insomnia and sleep apnea.

He explains that the primary active compounds in marijuana—tetrahydrocannabinol (THC) and cannabidiol (CBD)—may have different effects on sleep. However, the effects of both compounds are not fully known. The nearly infinite number of variations in cannabis plants with different levels of THC and CBD confounds the research process. Dr. Kolla adds that studies are often dubious because researchers have relied on recreational marijuana users who obtained the drug from uncontrolled sources.

However, studies have revealed, to some degree, how cannabis affects sleep. The takeaway here for any physician, Dr. Kolla says, is that weed will certainly have at least some adverse effect on sleep.

“What we know from the controlled trials is that it doesn’t seem to affect REM sleep that much,” he says. “From the recreational cannabis use studies, we know that N3 sleep is affected.”

Dr. Kolla explains that sleep takes place in stages: N1, N2, N3, and REM (when we dream). The N stages are when deep sleep takes place, with N3 being the deepest stage. So, cannabis users may be missing out on the deepest stage of sleep.

“But more important than that, I think, is that when people stop smoking weed, sleep is quite distant,” Dr. Kolla says. “It takes longer to fall asleep. Subjectively, they feel that the sleep quality is poorest. They’re waking up more often.”

In other words, there’s a Catch-22 with cannabis and sleep. People might take it to get to sleep more easily, but they’re inadvertently cheating themselves on deep sleep. And, if they try to quit, their sleep really suffers.

“A lot of patients—as many as two-thirds in some studies—who are trying to quit recreational use [eventually] go back to smoking weed,” Dr. Kolla says. “Once they’ve stopped, their sleep is disturbed and they think, ‘If I go back to smoking weed, I can maybe sleep better.’ But cannabis changes sleep to a degree where users are more or less dependent on it.”

Cannabis for sleep apnea

According to Dr. Kolla, the AASM’s stance against cannabis is due to insufficient research and the inconsistency of different strains of cannabis.

“When we talk about cannabis, there’s more than 100 compounds in the plant,” he says. “A lot depends on the source…of what compound somebody is taking. A lot of times, it’s very hard to tell what somebody is taking because there is little quality control.”

The lack of consistency from plant to plant and strain to strain makes researching the effects of cannabis on sleep very difficult. However, researchers of one study looked at the effects of dronabinol, an iteration of THC, on obstructive sleep apnea. They concluded that “findings support the therapeutic potential of cannabinoids in people with OSA. In comparison to placebo, dronabinol was associated with lower [Apnea-Hypopnea Index, AHI], improved self-reported sleepiness, and greater overall treatment satisfaction.”

The study also cited the need for larger-scale research, which is at the heart of Dr. Kolla’s criticism.

“The Apnea-Hypopnea Index, which is how we measure the severity of sleep apnea, improved ever so slightly,” he says, noting that AHI improved about 2 to 4 points. “That is currently completely meaningless for us. Because we are usually treating patients where the numbers are, say 15 and over in the AHI, and we are aiming to try and get that number under 5. So, if THC reduces it by about 2 points, or maybe 4 points, that really doesn’t treat sleep apnea.”

As a result, the AASM issued a position paper that cannabis should not be used as a therapy for sleep apnea. Dr. Kolla and his colleagues also released a position paper of their own through Mayo Clinic Proceedings, in which they stated that the use of cannabis to treat sleep apnea is “extremely premature and has the potential to result in inadequate treatment and possible harm.”

Recreational use

For your patients who are recreational users and are looking to mitigate the effect of cannabis on sleep, Dr. Kolla has some bad news: Their sleep will be disturbed.

“I think it will have some effect, no matter what,” Dr. Kolla says. “People are different and the compounds are different, so it’s hard to predict how each person will react to what they’re taking. So, if they find that it’s disrupting sleep, that it’s impacting their quality of life, that’s their answer. They probably should reconsider their views.”