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STIMULANTS, CANNABIS, AND CLUB DRUGS (AJ BUDNEY, R VANDREY AND D LEE, SECTION EDITORS)
Sleep Disturbances: Implications for Cannabis Use, Cannabis Use
Cessation, and Cannabis Use Treatment
Kimberly A. Babson &Marcel O. Bonn-Miller
Published online: 18 March 2014
Abstract Cannabis may be used, among certain individuals,
for its actual and/or perceived sleep-promoting properties.
Although evidence suggests that cannabis is likely beneficial
for sleep initiation, over time individuals may develop toler-
ance to these benefits, leading to greater use in order to
maintain the same sleep-inducing effects. This form of use
likely contributes to the development of problematic cannabis
use patterns, including cannabis use disorders. Evidence also
points to sleep as an important consideration in terms of
understanding cannabis withdrawal and relapse. Here, sleep
disturbances have been reported as a primary symptom of
withdrawal, with studies revealing that this increase in sleep
disruption during discontinuation of cannabis use may be a
significant risk factor for relapse. Therefore, it is likely impor-
tant to consider interventions aimed at providing alternative
means to cope with and/or treat sleep disturbances (e.g.,
behavioral or pharmacological approaches) as adjuncts to
interventions for cannabis use disorders to improve treatment
outcomes.
Keywords Cannabis .Sleep .Cannabis withdrawal .
Cannabistreatment .Cannabis use disorders .Insomnia .Sleep
disturbances
Introduction
Approximately 97 million Americans over the age of 12 years
(31 % of the overall population) have tried cannabis, with 4.3
million Americans (1.3 % of the population) meeting the
criteria for problematic cannabis use (defined as hazardous
use, abuse, or dependence) in 2009 [1]. On the basis of this
prevalence pattern, it has been estimated that the need for
cannabis use disorder (CUD) treatment will more than double
by 2020 [2]. Contingency management, motivational en-
hancement, and cognitive behavioral interventions are cur-
rently the most efficacious evidence-based interventions of-
fered for treatment of CUDs [3]. Despite the presence of such
effective interventions, and patients’desire to quit, cannabis
use cessation attempts are often met with high rates of lapse
and relapse [4–6], indicating significant room for improve-
ment in the treatment of problematic cannabis use.
Previous research has shown that 63 % of adults engaged in
cannabis use treatment (i.e., cognitive behavioral intervention
and motivation enhancement) relapse (defined as a return to
the previous level of use or abandonment of the abstinence
goal) to regular use within 4 months, with the rates of relapse
increasing to over 70 % by 16 months [7]. In addition to full
relapses, recent work has demonstrated that lapses (defined as
a slip or violation of the abstinence goal) are also common.
Moore and Budney [5] demonstrated that among outpatient
K. A. Babson
Center for Innovation to Implementation, VA Palo Alto Health Care
System, 795 Willow Road (152-MPD), Menlo Park, CA 94025,
USA
K. A. Babson (*)
Department of Psychiatry and Behavioral Sciences, Stanford School
of Medicine, 401 Quarry Road, Stanford, CA 94305-5717, USA
e-mail: kbabson@stanford.edu
M. O. Bonn-Miller
Center of Excellence in Substance Abuse Treatment and Education,
Philadelphia VA Medical Center, 3900 Woodland Avenue,
Philadelphia, PA 19104, USA
e-mail: marcel.bonn-miller@va.gov
M. O. Bonn-Miller
National Center for PTSD & Center for Innovation to
Implementation, VA Palo Alto Health Care System, 795 Willow
Road (152-MPD), Menlo Park, CA 94025, USA
M. O. Bonn-Miller
Department of Psychiatry, Perelman School of Medicine, University
of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
Curr Addict Rep (2014) 1:109–114
DOI 10.1007/s40429-014-0016-9
#Springer International Publishing AG (outside the USA) 2014
adults engaged in treatment for a CUD, 24 % lapsed by
1 month, 46 % within 3 months, and 71 % within 6 months.
For this reason, it is important to identify malleable mecha-
nisms implicated in poor cannabis use cessation outcomes to
improve and generally refine existing treatments for CUD.
Sleep disturbance is one factor which has shown recent theo-
retical and empirical promise in terms of understanding can-
nabis use and predicting cannabis use cessation outcomes. By
understanding the role of sleep in regard to cannabis use, one
may optimize interventions for individuals with CUD.
The purpose of this review is to highlight the existing
literature pertaining to the comorbidity between cannabis use
and sleep disturbances, including implications for future em-
pirical work and treatments. We begin by discussing the
neurobiological underpinnings of the association between
sleep and cannabis, followed by a discussion of clinical work
aimed at understanding how disturbed sleep may lead to
cannabis use. Next, we discuss mechanisms by which canna-
bis use may lead to increased difficulties with sleep, including
how sleep may affect cannabis use cessation outcomes.
Neurobiology of Sleep and Cannabis Comorbidity
Preclinical and clinical research demonstrates that cannabis
alters the sleep–wake cycle [8]. Cannabis comprises a multi-
tude of chemical compounds, with the primary psychoactive
constituent being Δ
9
-tetrahydrocannabinol (Δ
9
-THC), which
has neural implications that are mediated through cannabinoid
(i.e., CB1) receptors located in the brain [9]. One of the
primary neural effects of Δ
9
-THC is sedation [10]. There are
two primary mechanisms proposed to explain this impact.
First, endogenous cannabinoids have been shown to increase
the level of adenosine, a sleep-promoting agent [11]. Second,
neurons in the lateral hypothalamus involved in regulation of
arousal systems express CB1 receptors, resulting in inhibition
of the arousal system [11]. Some studies have shown that
immediate administration of Δ
9
-THC reduces sleep latency
[12]. However, in studies using high-dose Δ
9
-THC, or among
cannabis-naïve participants, Δ
9
-THC tends to have an activat-
ing responsethat has been associatedwith increased latency to
sleep onset [13–15]. These contrasting findings could also be
explained by work that has shown that Δ
9
-THC may have a
biphasic influence whereby stimulating effects are first expe-
rienced, followed by sedating effects [16].
Cannabidiol (CBD) is a nonpsychoactive component of
cannabis that can counter the excitatory effects, and potentiate
the sedative effects, of Δ
9
-THC [8]. CBD administered imme-
diately has been shown to perform as a short-acting hypnotic
in rats [8]. Specifically, CBD administration has been shown
to have sleep-inducing (with a 20 mg/kg dose) and sleep-
maintenance (with a 40 mg/kg dose) qualities in rats, with
tolerance to these effects developing after long-term
administration [8]. However, among humans, administration
of CBD (i.e., 15 mg) has been shown to have an alerting
affect, which can counter the sedating qualities of Δ
9
-THC
[17]. Despite the disparate findings regarding the individual
effects of Δ
9
-THC and CBD, when combined, Δ
9
-THC and
CBD appear to have an antagonistic effect on each other in
terms of the sleep–wake cycle [8,18]. Together, the dose and
the timing of administration appear to be important factors to
consider when evaluating the impact of Δ
9
-THC and CBD.
Both cannabis and sleep disturbances have also been asso-
ciated with reduction of activity in the same regions of the
prefrontal cortex [19–22]. The prefrontal cortex has been
shown to play a primary role in normal sleep, and reductions
in activity in the prefrontal cortex have been observed among
individuals with insomnia [21] or sleep deprivation [22], and
among heavy cannabis users abstinent for 30 days [19]. The
orbitofrontal cortex (OFC) has been a region of particular
interest, as both discontinuation of cannabis use and insomnia
are associated with decreased OFC glucose metabolism [21,
23], and Δ
9
-THC administration has been associated with
increases in OFC glucose metabolism, which may function
to decrease insomnia [24]. Taken together, these cortical dis-
ruptions offer a potential model from which to understand the
association between sleep disturbance and cannabis use.
Poor Sleep Can Contribute to Coping-Oriented Cannabis
Use
Understanding the reasons or motives for substance use is also
helpful for grasping the nature of substance use behavior.
Recent work has demonstrated that individuals, particularly
those with psychological vulnerabilities, for example, post-
traumatic stress disorder (PTSD), other anxiety disorders, and
depression, may use cannabis for coping-related reasons
[25–28]. Those reporting coping as a primary motive for
cannabis use have been shown to be at higher risk of elevated
frequency and amount of use, as well as the development of a
CUD [29–32]. Following from this line of work, there has
been a developing focus on understanding specific states or
symptoms for which individuals use cannabis to cope.
Sleep disturbances have emerged as a set of symptoms for
which individuals appear particularly apt to use cannabis for
coping reasons [33••]. Research has suggested that adminis-
tration of an oromucosal cannabis-based medicine extract
(2.7 mg Δ
9
-THC, 2.5 mg CBD) improves short-term sleep
problems among individuals with insomnia and chronic pain
[34]. This initial empirical work is further supported by neu-
robiological research demonstrating that the psychoactive
components of cannabis, such as Δ
9
-THC, may facilitate the
onset of sleep [34,35]. However, over time, individuals may
habituate or develop tolerance to the sleep-inducing and self-
reported sleep-enhancing qualities of cannabis, thereby
110 Curr Addict Rep (2014) 1:109–114
requiring more in order to obtain the same desired result [36].
Indeed, the beneficial effect of cannabis on self-reported sleep
quality is less frequently noted among long-term cannabis
users [36].
Clinical research has also provided evidence for the use of
cannabis as a means to cope with sleep disturbances among
adults and adolescents. For example, among adolescent canna-
bis users without a use disorder (aged 16–22 years), 69.6 %
reported using it to sleep [37]. Lower rates have been observed
among regular long-term cannabis users (i.e., those using can-
nabis for at least 10 years), of which 50 % reported using
cannabis to improve sleep [38]. Among medical cannabis
patients, Bonn-Miller el al. [39] demonstrated that 48.1 % use
cannabis to aid with insomnia, whereas slightly higher rates
have been observed among medical cannabis patients receiving
cannabis for physical health reasons [40]. Indeed, of those
receiving medical cannabis for treatment of pain, 83–85 %
reported improved sleep, with higher rates of sleep benefit
observed among those with mood disorders (93 %) [40].
The use of cannabis for sleep promotion has also been
observed among nonmedical users with psychological disor-
ders, with 69.4 % of individuals with psychosis reporting
cannabis use to improve sleep [41]. Among a sample of
individuals with PTSD, Bonn-Miller et al. [42]demonstrated
that, compared with women with PTSD who self-reported
relatively good sleep, women with elevated symptoms of both
PTSD and disturbed sleep were more likely to report using
cannabis as a means to cope. A follow-up study among
medical cannabis patients demonstrated that those with ele-
vated symptoms of PTSD used medical cannabis for the
purposes of improving sleep, and that this pattern was associ-
ated with a heightened frequency of cannabis use [33••].
Taken together, research on coping motives among indi-
viduals with and without psychological vulnerabilities sug-
gests that cannabis may initially serve to promote sleep initi-
ation among individuals with sleep difficulties. However, the
continued use of cannabis for these reasons may actually lead
to long-term deficits in sleep architecture and severer cannabis
use patterns. What follows from this work is a cyclical model
whereby cannabis is used to cope with initial sleep difficulties
that may or may not be associated with a psychological
disorder (e.g., PTSD). As cannabis is used to cope with sleep
difficulties, individuals may find that they begin using more
cannabis than initially intended, with tolerance developing
over time. Such heightened cannabis use then likely leads to
greater disturbances in sleep during periods of abstinence,
which can then prompt a return to cannabis use.
Sleep Disturbance as a Cannabis Withdrawal Symptom
A breadth of laboratory-based studies have identified sleep
disturbance as a salient symptom of cannabis withdrawal
[43–46]. Controlled studies have shown that sleep distur-
bances increase during periods of abstinence and remit during
periods of cannabis use [43]. An outpatient study of cannabis
use cessation demonstrated that sleep disturbance was elevat-
ed over the course of a 45-day abstinence period [44], and
studies of inpatient non-treatment-seeking regular users have
demonstrated that withdrawal from cannabis increases both
self-reported and objectively measured (i.e.,
polysomnography) sleep disturbances. Resumption of canna-
bis use [43], and oral administration of both low (30 mg/day)
and high (90 mg/day) doses of Δ
9
-THC have been shown to
alleviate these sleep problems [46–48].
In contrast, one study demonstrated no effect of orally
administered Δ
9
-THC on objective measures of sleep within
the context of cannabis withdrawal [49], whereas in a second
study, Haney et al. [50]demonstratedthatorallyadministered
Δ
9
-THC (60 mg/day) increased sleep onset latency during
cannabis abstinence. However, in this same study, a combina-
tion of lofexidine and orally administered Δ
9
-THC resulted in
significant improvements in both self-reported and objectively
measured sleep during cannabis use cessation.
In a more recent study, Vandrey et al. [51••]specifically
examined the effect of addressing poor sleep during cannabis
withdrawal in a within-subject crossover study among 20
daily cannabis users. The participants completed alternating
periods of cannabis use and abstinence in a controlled envi-
ronment. During a single abstinence phase, a sleep medication
(zolpidem) was administered, and a placebo pill was admin-
istered during a second abstinence period. This study demon-
strated that during the placebo abstinence phase, the partici-
pants experienced reductions in sleep efficiency, sleep time,
stage 1 and stage 2 sleep, REM latency, and self-reported
sleep quality. The participants also demonstrated an increase
in sleep onset latency and the amount of time spent in REM
sleep compared with periods of cannabis use. Administration
of zolpidem attenuated all sleep disturbances except increases
in sleep onset latency.
In summary, outpatient and inpatient studies combined
have identified sleep disturbance as a salient cannabis with-
drawal symptom. Administration of cannabis (through either
smoking or oral administration of Δ
9
-THC), sleep medication
[51••], and a combination of lofexidine and orally adminis-
tered Δ
9
-THC have all been shown to attenuate withdrawal-
related sleep disturbance.
Sleep Disturbance Increases the Risk of Cannabis
Lapse/Relapse
As sleep disturbance has been documented as a cannabis
withdrawal symptom, it is not surprising that poor sleep has
been shown to be one factor that is predictive of lapse/relapse
to cannabis use [44,45,52,53••,54••]. Retrospective studies
Curr Addict Rep (2014) 1:109–114 111
first documented these associations. In one study, 67 daily
cannabis users who had made a cannabis use cessation attempt
in the previous 30 days were interviewed by phone regarding
perceptions of withdrawal symptoms. Of this sample, 65 %
indicated that poor sleep was a primary symptom that led to
their relapse [45]. Furthermore, in two studies of non-
treatment-seeking cannabis users, 32–47 % reported poor
sleep during a previous time of abstinence, and 48–77 %
indicated that they had relapsed to cannabis use or increased
the use of other substances in order to improve sleep quality
[55,56].
The role of sleep on cannabis use lapse/relapse has
also been supported by laboratory-based experimental
work. Haney [52] demonstrated that decreases in sleep
disturbance resulted in decreased risk of lapse/relapse to
cannabis use (as measured by a laboratory analog task).
More recently, sleep disturbance among cannabis-
dependent veterans prior to a cannabis use cessation
attempt was shown to be predictive of increased risk
of lapse within the first 2 days of the cessation attempt
[54••], and heightened cannabis use during the 6 months
following the cessation attempt [53••]. In contrast to
these findings, studies have demonstrated that a number
of medications shown to improve withdrawal-related
sleep disturbances (i.e., lofexidine, mirtazapine,
quetiapine) have not led to reductions in the risk of
lapse/relapse to cannabis use in the laboratory model
developed by Haney et al. [50,57,58].
Clinical Implications
A breadth of research has demonstrated the efficacy of both
pharmacological (e.g., benzodiazepine hypnotics) and behav-
ioral (cognitive behavioral therapy for insomnia, CBT-I) in-
terventions for the treatment of insomnia and sleep distur-
bances [59–61]. Comparisons between pharmacotherapy and
behavioral interventions have demonstrated comparable treat-
ment effects, with pharmacotherapy offering a more immedi-
ate impact on sleep and behavioral interventions linked to
greater long-term and sustained treatment gains [62–64].
Studies have demonstrated that the best sleep treatment out-
comes are observed among individuals who are initially treat-
ed with a combination of pharmacotherapy and behavioral
interventions and then continue treatment only with the be-
havioral intervention [64]. Although treatment effectiveness
exists for both forms of intervention, it is important to note
that no study has examined comparative efficacy or effective-
ness of these interventions among individuals with a history of
substance use disorders. This limitation of existing work is
likely due to the fact that pharmacotherapy for insomnia is
typically not recommended for individuals with a history of
substance use disorders owing to the risk of the development
of dependence [61]. For this reason, additional research
among substance use populations is needed.
Although the findings of recent work have converged
to demonstrate that sleep disturbances impact substance
use and quit success, this research is still in its infancy,
particularly in relation to the evaluation of sleep inter-
ventions for substance use outcomes. Although the im-
pact of CBT-I or sleep medications on cannabis use
cessation has yet to be thoroughly evaluated, research
drawing from the treatment of alcohol use disorders
provides some insight. Research has shown that among
individuals recovering from alcohol dependence, behav-
ioral interventions (e.g., CBT-I) improve self-reported
and objective measures of sleep immediately after the inter-
vention [65,66]andat3and6monthsaftertheintervention
[65]. However, there has yet to be any documentation of an
effect of behavioral sleep interventions on alcohol use cessa-
tion outcomes (e.g., abstinence, relapse) [65,66].
Despite the extensive research support for pharmaco-
therapy and behavioral interventions for insomnia, wide-
spread dissemination and integration of these interven-
tions into specialty care treatment centers (e.g., sub-
stance abuse treatment) has been limited. For this rea-
son, additional research is needed to understand the
potential impact of administering a sleep intervention
prior to, or within the context of, CUD treatment.
Conclusions
Although there remains a general dearth of literature on
the associations between sleep disturbance, cannabis
use, and cannabis use cessation, existing work points
to a cyclical relation whereby cannabis use is main-
tained, and likely initiated, by sleep disturbances stem-
ming both from symptoms of existing psychopathologi-
cal disorders and periods of cannabis abstinence.
Therefore, interventions that provide an alternative
method to cope with disturbed sleep may not only
decrease the perceived need to use cannabis to cope
with sleep problems, but may also potentially lessen
the salience of sleep-related cannabis withdrawal, de-
creasing the risk of lapse/relapse. Although studies of
sleep interventions among alcohol users provide some
evidence for the utility of cognitive behavioral therapy
for co-occurring sleep disturbances, clinical trials exam-
ining the impact of such interventions on substance use
outcomes are lacking. Future work would benefit from
the investigation of the impact of behavioral and phar-
macological sleep interventions, either as standalone
interventions or as an adjunct to other interventions,
for individuals with co-occurring sleep disturbance and
cannabis use.
112 Curr Addict Rep (2014) 1:109–114
Compliance with Ethics Guidelines
Conflict of Interest Kimberly A. Babson and Marcel O. Bonn-Miller
declare they have no conflict of interest.
Human and Animal Rights and Informed Consent All procedures
followed were in accordance with the ethical standards of the responsible
committee on human experimentation (institutional and national) and
with the Helsinki Declaration of 1975, as revised in 2008. Informed
consent was obtained from all patients for their inclusion in the study.
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