Treatment of Insomnia: Cannabis Reconsidered
For some patients, cannabis may offer help with sleep.
Posted Mar 31, 2017
A lot has changed since my last post on the potential use of cannabis for insomnia. At that time, just before the election in 2012, I concluded that there was insufficient research to say definitively whether or not cannabis might be useful in treating insomnia. Since then there has been a sea change in the public and political acceptance of using this plant as a drug. More research has been conducted and medical marijuana has become much more available around the country. Legal recreational marijuana has also become a reality in a number of states.
Work on the therapeutic uses of cannabis is one aspect of the “psychedelic renaissance” (Sessa, 2012) that has been taking place globally for many years but especially since 2010. Years in development, this movement is taking a second look at substances with psychedelic effects that were outlawed during the early days of the Drug War. We live in a society, and at a time, in which many people are suffering the effects of trauma and the stress of vast economic, scientific, ecological, and technological changes. Poor sleep is a common effect of stress and trauma. Conventional psychiatric and psychological treatments often don’t seem adequate to the challenges we are facing. They tend to manage, rather than cure disorders, and reduce rather than eliminate suffering. Standard psychological treatments, such as cognitive behavioral therapy of depression may be less effective than in the past and truly new psychiatric medications are not coming on line as quickly as they had been in past decades. For these reasons, courageous researchers (Sewell, et al., 2006). around the world have started to again investigate the use of this stigmatized class of drugs as possible treatments or even cures for the psychological suffering so many experience in the present.
Cannabis is the world’s most used illicit substance. The first move toward approving the medical use of it came in 1991 when Proposition P was passed by voters in San Francisco. Proposition P urged the state of California to make cannabis available for medical use. It should be remembered that at that time we were trying to cope with the terrifying AIDS epidemic and help for patients was urgently needed. Cannabis was first approved for legal medical use at the state level California in 1996 and many other states followed suit. In 2001 Portugal decriminalized the use of all psychoactive drugs and has had generally positive results following this change in approach.
The title of this post was inspired by two important books written by Grinspoon in the 1970’s (Grinspoon, 1971, 1977; Grinspoon, & Bakalar, 1979). These books were written just after the Drug War began in 1971 when President Nixon declared “war on drugs” and massively increased federal efforts to control use through enhanced federal enforcement. Most of the drugs considered in these books, including marijuana, were placed on Schedule 1 of controlled substances, meaning that they had significant potential for abuse and no accepted medical use. What was meant by abuse was left ambiguous by the 1970 controlled substances law and was essentially whatever the Drug Enforcement Agency declared it was. Under the scheduling system congress got out of the business of outlawing psychoactive drugs and gave that responsibility to a regulatory agency. Despite this, in the 1970’s, 11 states decriminalized marijuana. This move toward decriminalization ended with the election of Ronald Reagan. Along with a renewed Cold War, there was a renewed Drug War. The official approach to the control of substance use has gradually shifted since California legalized medical cannabis and Portugal decriminalized all drugs.
The issue of the therapeutic use of cannabis has gained further significance over the past few years and especially since the election of 2016. The election was, as many have noted, unusual and unexpected. Democratic candidates did not fare well. Despite this, liberal causes did reasonably well at the ballot box and cannabis had an especially good night.
Voters passed proposed cannabis laws in nine states. Of these, four were for medical cannabis and five were for recreational use. Remarkably, all of the medical and four of the five recreational laws passed. As a result, over half of the states now have medical cannabis laws and about one fifth of American adults can use it legally for recreation. Connecticut, where I am located, has had a medical cannabis program for a number of years and nearby Massachusetts added recreational use in 2016. Connecticut is considering legalization for recreational use. The Drug Enforcement Agency has recently also relaxed some restrictions on research into the therapeutic uses of cannabis. Despite the results of the 2016 election and the easing of restrictions on research, questions remain about the future of cannabis under federal law.
I am asked by patients about the Connecticut medical marijuana program several times a week. The program is rather restrictive compared to other programs around the country but there was a very important reason for this. When the bill was crafted it was decided to focus on providing medical marijuana only for conditions that had strong empirical support for use as a treatment. The conditions that are approved are: cancer, glaucoma, HIV, AIDS, Parkinson's disease, multiple sclerosis, damage to the nervous tissue of the spinal cord with objective neurological indication of intractable spasticity, epilepsy, cachexia, wasting syndrome, Crohn's disease, and post-traumatic stress disorder. The Connecticut medical marijuana web site is quite good and even gives links to the programs in other states.
Note that insomnia is not on this list. While I have no official report or published data that I can refer to, I have been told that, at least for some dispensaries in Connecticut, the primary diagnosis that results in referral to the program was PTSD, while the problem that patients most often reported as a reason for using medical marijuana was insomnia.
Now it turns out that cannabis is an incredibly complex plant substance and its psychoactive components are equally complex. I want to discuss some of this complexity in the interest of helping people better understand the potential benefits and risks of using cannabis for sleep problems. I will therefore, over the next several posts, go into greater depth about this fascinating plant and its possible role in the treatment of sleep disorders. I will be covering issues including the psychopharmacology of cannabis, the psychological and physical effects of its use as a drug, and what all of this may mean going forward for using medical cannabis as a treatment for sleep disorders.
Grinspoon, L. (1971, 1977). Marihuana Reconsidered. Cambridge, MA: Harvard University Press.
Grinspoon, L. & Bakalar, J.B. (1979). Psychedelic Drugs Reconsidered. New York: Basic Books, Inc.
Sewell, R.A. et al. (2006). So You Want to be a Psychedelic Researcher? The Entheogen Review, 15 (2), p 42 – 48.
Sessa, B. (2012). The Psychedelic Renaissance: Reassessing the Role of Psychedelic Drugs in 21st Century Psychiatry and Society. London: Muswell Hill Press.