Chronic insomnia in otherwise well adults is a complex disorder that often has multiple
aetiologies. Both pharmacologic and psychological treatment is indicated for optimal
treatment, but this depends on medical, psychiatric factors, and chronicity of symptoms.
Causes of chronic insomnia are complex, and often linked with comorbidities including depression, chronic pain, and other illness. Cognitive behavioural therapy shows strong efficacy and is recommended for the long-term management of chronic insomnia.
Patients with acute insomnia (< 1 month) may require short-term medication in conjunction with sleep hygiene education. If the insomnia is causing significant distress, limited short term use of short or intermediate acting benzodiazepines may be needed. Most sleep medications are not recommended for use beyond three months, with hypnotics for only four weeks.
Research into medicinal cannabis and insomnia suggests positive therapeutic potential for the treatment of insomnia.
The two principal cannabinoids, THC (tetrahydrocannabinol) and CBD (cannabidiol), have
different effects on sleep. Studies show that CBD shortens the time it takes to fall asleep, and
lengthens the time spent in deep, slow wave sleep. THC also shortens the amount of time
spent in REM sleep.
CBD is a non-psychotropic cannabinoid compound that promotes relaxation. It will not alter cognition or cause a ‘high’ but can cause drowsiness. Evidence also points to a calming effect for CBD in the central nervous system.1 Studies show that it reduces anxiety without affecting sleep-wake cycles.
Prolonged use of high THC products can reduce the quality of sleep over the long-term and high CBD use over the long term has the potential to reduce the amount of REM sleep.
Medical cannabis is safer than many other prescription and OTC medications currently
available to treat insomnia.
CBD: The use of low-dose CBD to reduce anxiety and concomitant early morning waking has been shown to improve restful sleep and additionally lead to a reduction in the use of benzodiazepines and alcohol.
THC: Low dose THC is highly effective at reducing sleep latency.
Combination therapy: A combined dose of CBD with low-dose THC as short-term therapy may help patients re-establish good sleep hygiene practices.
Treatment may also help people who suffer with chronic pain disorders – as reduced pain symptoms will support improved sleep.
Patients with psychophysiologic insomnia – a behavioural issue where the abnormal sleeping
patterns acquired during a transient period of stress have persisted – may have the strongest
benefit from insomnia management with medicinal cannabis.
Harm minimisation prescribing is also a key consideration, with prescribed medical cannabis showing good outcomes for patients with escalating self-medication behaviours, particularly in the use of benzodiazapines and/or opioids. 2
Avoid prescribing high-THC dose medicinal cannabis in patients with insomnia with comorbid anxiety as this may exacerbate symptoms.
Suitable patients include those with:
1. Shannon S, Lewis N, Lee H, Hughes S. Cannabidiol in Anxiety and Sleep: A Large Case Series. Perm J. 2019;23:18‐041.
2. Chad Purcell, Andrew Davis et al. Reduction in Benzodiazepine Use in patients Prescribed Medical Cannabis.
Cannabis Cannabinoid Res. 2019; 4(3): 214-218
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