Meet the Practitioner
I’m Green Care Medical’s Chief Medical Officer, and have been a trauma surgeon and surgical intensivist for over 20 years. Since founding Green Care Medical, my practice has focused on treating patients with sleep disorders and complex pain syndromes. Outside of my clinical practice, I’m involved in resident and fellow education at hospitals where I am on staff, and sit on a number of philanthropic and outreach boards.
Dr. Steven Salzman
Key Takeaways
- Sleep is among the most important processes of the human condition.
- Insufficient sleep, which includes insomnia, is a major ongoing public health issue.
- Cannabidiol (CBD) is one of hundreds of cannabinoids, and one of the two most prominent, naturally occurring in the cannabis plant.
- Anecdotally, CBD has helped thousands of patients achieve better sleep.
Background
Insufficient sleep, which includes insomnia, is a major ongoing public health issue. The American Academy of Sleep Medicine reports fifty to seventy million US adults having a sleep disorder. Additionally, half of all Americans say they fall asleep during the day at least three days per week. More disconcerting is that 37.9% of these patients reported falling asleep unintentionally during the day at least once in the preceding month, and 4.7% reported nodding off or falling asleep while driving at least once in the preceding month (1). Drowsy driving is responsible for 1,550 fatalities and 40,000 non-fatal injuries annually in the U.S. Additionally, 100,00 deaths occur each year in U.S. hospitals due to medical errors that are often a direct consequence of sleep deprivation.
Sleep is among the most important processes of the human condition. It impacts almost every level of body homeostasis. Cardiovascular and immune function, hormone production and regulation, mood, and brain function, as well as many other systems, are significantly impacted by the amount and quality of one’s sleep. Research demonstrates that the Endocannabinoid System (ECS) is involved in the regulation of the Circadian sleep-wake cycle, including the maintenance and promotion of sleep. It is hypothesized that the ECS serves as the link between the circadian regulation systems (CRS) and the behavioral and physiological processes that are affected including sleep (2). The role of the ECS in the CRS has been further supported by research demonstrating that a lack of normal sleep causes dysregulation within the ECS, while elevation in the ECS at the receptor level is involved in the homeostatic recovery of sleep after non-normal sleep (3). While research continues to evolve, it is clear the ECS is the critical system involved in the regulation of the circadian sleep-wake cycle.
Cannabidiol (CBD) And Sleep
Cannabidiol (CBD) is one of hundreds of cannabinoids, and one of the two most prominent, naturally occurring in the cannabis plant. The precise impact CBD has on the sleep-wake cycle remains unclear. Its promotion of healthy sleep varies based on dosage. Generally, low-dose CBD has a more stimulating effect while higher dosing tends to be more sedating. One study with insomnia patients showed CBD increased total sleep time and decreased the frequency of arousals during the night (4). Other studies have shown that low-dose CBD has been associated with increased wakefulness (5,6). A recent study on sleep and early morning behavior demonstrated CBD’s impact on wakefulness. CBD administered in a 1:1 ratio counteracted the sedative effect of THC (5). CBD may also hold promise in treating REM-sleep behavior disorders as well as excessive daytime sleepiness.
A Wide Dosing Range
To date, there are no randomized, double-blinded prospective trials to definitively guide practitioners on precise dosing for individual patients experiencing problems with sleep. Most clinical trials concerning CBD and sleep involve administering between 25 mg and 1500 mg of CBD per day, a wide variation.
Clinical Practice And Dosing Regimen
Clinical experience treating sleep issues with CBD has led to the development of a dosing protocol in my practice. Generally, I recommend most adult patients start with a low dose (25-50mg), and increases slowly, titrating to the desired effect (longer, more restorative sleep). I also counsel them on the importance of limiting exposure to common sleep-disruption contributors: stimulants, alcohol, excessive napping, various medications or underlying medical conditions, and electronic devices of all types.
Anxiety Reduction
Repairing sleep can also improve patients’ anxiety, often seen in practice as a secondary manifestation of ongoing insomnia and chronically insufficient sleep. While CBD can potentially improve sleep, its properties can also help relieve crippling anxiety by contributing to patients’ overall sleep improvement.
In 2019, a large, retrospective case series at a psychiatric clinic involving the clinical application of CBD for anxiety and sleep complaints as an adjunct to usual treatment was reviewed. The retrospective chart review included monthly documentation of anxiety and sleep quality in patients. Anxiety scores decreased within the first month in 79.2 % of the patients and remained decreased during the study duration, and sleep scores improved in 66.7% of the patients within the first month (7).
Bottom Line
Anecdotally, in my practice, CBD has helped thousands of patients achieve better sleep. CBD, THC and other cannabinoids, has proven their medical value for thousands of patients, and warrant a place in the conversation as first-line therapy options. More robust studies and data are needed to further understand additional benefits of CBD on sleep disorders and other, related conditions.
Resources
1. Statistics gathered from American Academy of Sleep Medicine Website and Sleep Foundation Website (updated February 8, 2021)
2. Sanford AE. Cannabinoids and hamster circadian activity rhythms. Brain Res. 2008; 1222:141-8
3. Vaughn LK, Denning G, Stuhr KL, deWit H, Hill MN, Hillard CJ. Endocannabinoid signaling: has it got rhythm? Br J Pharmacol. 2010; 160(3):530-43
4. Carlini EA, Cunha JM. Hypnotic and antiepileptic effects of cannabidiol. J Clin Pharmacol. 1981;21(8-9 Suppl):417S-27S
5. Nicholson AN, Turner C, Stone BM, Robson PJ. Effect of Delta-9-tetrahydrocannabinol and cannabidiol on nocturnal sleep and early morning behavior in young adults. J. Clin Psychopharmacol. 2004;24(3):305-13
Zuardi AW. Cannabidiol: from an inactive cannabinoid to a drug with wide spectrum of action. Rev Bras Psiquiatr. 2008;30(3):271-80
Shannon S, Lewis N, Lee H, Hughes S. Cannabidiol in anxiety and sleep: A large case series. Perm J. 2019;23:18-041
Disclaimer Statement: These recommendations are based on the clinician author’s professional experience, and have not been reviewed by the FDA.
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