According to the National Sleep Foundation, some 50 to 70 million Americans experience insomnia at some point in their lives. Based on what I'm hearing from my patients, this number is through the roof thanks to the scourge of COVID. If getting some shut-eye is becoming harder for you, know that you're not alone.
Make no mistake; sleep is crucial to our physical and mental functioning. The most recent research indicates that sleep is essential to all of the body's repair and restore functions. When we are at rest, the body learns what's wrong and physically "relearns" how to contend with the complexities and stressors of everyday life. Restful sleep has been proven to improve memory recall, regulate metabolism, and reduce mental fatigue. During sleep, the brain reorganizes and recharges itself, and the body removes waste byproducts that have accumulated throughout the day. It's almost as if our dream life represents our struggle to get back to balance.
When people are sleep deprived, they suffer. Their cognitive abilities decline, their behavior, and their judgment becomes erratic. Fatigue makes us more emotional, anxious; more strung out, more on edge. It's no fun, and yes, it gets worse as we age in large part due to hormones, prescription medications, and chronic diseases.
As you've probably noticed, not all sleep aids work for everyone. There is no perfect drug that produces a regular sleep and dream pattern like a genuinely restful night sleep does. Many medications produce a tolerance that requires higher and higher doses. When some people stop taking them, they suffer nasty withdrawal symptoms, including severe insomnia.
There's no conclusive evidence that cannabis works infallibly for everyone with insomnia. Still, my own clinical experience of treating patients with it for over 15 years shows it is at least as effective as conventional pharmaceuticals. Getting to the right dose requires some experimentation, so if you're not willing to invest a little time doing this, medical cannabis may not be a solution for you.
Below are some of the most common questions I'm hearing about insomnia and cannabis these days.
Why and how does cannabis work for sleep disruption?
Anxiety, stress, and chronic sleep deprivation all inhibit GABA, a naturally occurring brain chemical that directs neurons to slow down or stop firing. This neurotransmitter also helps to induce sleep, relax muscles, and calm down. In essence, GABA directs the body to chill out.
Cannabis modulates GABA, helping return the body to its more normal functions. Careful cannabis dosing may help stop the racing thoughts that cause disrupted sleep and panicked awakenings during the night. It can also be used to treat what is called "parasomnias," sleep disorders characterized by abnormal movements, behaviors, or perceptions during sleep, like jaw grinding, sleepwalking, or nightmares.
The cannabis molecules produced by your own body (endogenous cannabinoids) make you resistant to stress, similar to the way endorphins provide natural relief from pain. Integrating optimally dosed cannabis products can help bring the body back into a state of balance.
Some of the research I've read online and in blogs say marijuana is no better than sleeping pills, that it doesn't provide a good night's sleep, and robs the body of REM sleep.
Prescription sleep aids (i.e., Ambien, Lunesta, etc.) don't deliver a restorative sleep. They replace our normal sleep cycles and dreams and result in "counterfeit sleep" -- studies show they only increase natural sleep by 8 minutes. Instead, they produce a type of sleep amnesia -- you forget that you had a crappy night! Benzos (i.e. Xanax, Klonipin, etc.) are often prescribed for insomnia, but they are only supposed to be used short term, 2 - 4 weeks maximum. If taken longer than that, they can be as addictive as opioids. Weaning from Xanax and Ambien can take up to a year because of the severe withdrawal symptoms and emotional dependence.
THC will decrease the amount of time it takes you to fall asleep, however, it does block REM sleep just like alcohol. CBD also reduces the amount of time it takes to fall asleep and helps you get a more restful night's sleep. Combining both THC and CBD in the right dosage and ratio can be very useful in helping chronic sleep sufferers in my clinical experience.
I've heard that once I start using medical cannabis, I'll have to increase the amount I use constantly.
You can indeed build a tolerance to cannabinoids if you use them regularly. But it's also easy to reset or "resensitize" your receptors by stopping use for a few days. If you need increasingly higher doses of cannabinoids to get to sleep, simply take a break for 4 or 5 days. (You can take 2 to 5 mg of melatonin, or 650 mg of Valerian, and Magnesium Taurate while you take your cannabis holiday). Staying off cannabinoids for 4 or 5 days will allow your receptors to flush themselves out. After this break, you can begin again by taking a minimal amount -- one or two vapor puffs or a few milligrams of tincture -- until you feel a shift. Start there. You'll probably be surprised to learn that you'll get the same relief on a much lower dose. You can increase that dose slowly over the next few days if required.
CBD reduces the amount of time it takes to fall asleep, and it decreases overall body inflammation and calms the nervous system. If taken throughout the day in a microdose regime, it can balance your circadian rhythm and help you with effortless sleep.
I often notice that when something upsets me during the day, it comes back to haunt me in the middle of the night, and I wake up and can't get back to sleep. Any ideas on how to contend with this?
That's a stress response, and cannabinoids also work to mitigate stress. In these cases, 10-40 mg of CBD -- or in some cases CBD that is supplemented with 1-3 mg doses of THC -- can reduce the anxiety that occurs during the day.
Here's how CBD directs the brain to activate the parasympathetic nervous system, which induces a state of calm. It works well for social anxiety and everyday stress, plus more extreme forms of anxiety such as panic attacks. One small study showed it even "reduced anxiety in public speakers," so if you're gearing up for that online TED Talk, take note!
Some of my patients carry a CBD vape pen or tincture with them during the day. If they know they have a stressful situation like a job interview or a confrontation coming up; they use it in advance to help keep calm. Others use it to steady themselves after an anxiety-provoking situation. You may want to try these strategies.
I just can't get to sleep these days. My mind won't stop chattering.
To fall asleep faster, you'll want to use a CBD: THC combination before bedtime. A little THC is a good idea because, as the feelings of being mildly high taper off (60-90 mins), it produces a sedative effect that encourages sleep. Low light enhances CBD's calming effects.
I can get to sleep, but I'm up in the middle of the night and can't get back to sleep.
Can I use other supplements? Can I mix with sleeping pills?
Some of my patients alternate between cannabinoids, pharmaceuticals, and other supplements like 650 mg Valerian or 2 to 5 mg Melatonin, a hormone released in response to darkness. They find that alternating their meds produces different sleep quality and doesn't make them reliant on just one form of medication.
CBD. What is the right dose? Some say it makes you drowsy. Others say it makes you alert. What's the deal?
CBD can be either sedating or stimulating, depending on your endocannabinoid system and the dose. Generally, CBD doses higher than 40 mg may cause drowsiness while lower doses (under 40 mg) may cause alertness--this isn't true for everyone, and you'll need to experiment.
Everyone says I need to use Indicas to get to sleep, but last night, I vaporized an Indica strain, and my mind just raced all night. It was crazy.
Right. Indica and Sativa aren't the most reliable indications of effects. Research indicates that terpenes -- those powerful smell molecules that give cannabis its pungent odor -- are better guides to what might make you sleepy. If you're in a legal state, you'll be able to find the flower's terpene content by checking the lab tests. Any good dispensary staff can help you with this.
There are at least 17 terpenes in cannabis, and each strain has a different combination in a different amount. If you're shopping for sleep-inducing flowers be sure to look for strains (chemovars) high in linalool and myrcene. Avoid more stimulating strains with high amounts of pinene or limonene.
I have read about CBN.
What are some of CBN’s effects/benefits?
CBN is another cannabinoid that has stronger sedative properties than CBD. When THC degrades due to exposure to air and light, CBN is formed. CBN is prominent in old, dried cannabis flower. Consumed in large quantities, CBN can produce paranoia, something you might experience after smoking low-quality, improperly stored pot. Storing cannabis in airtight containers makes it last longer and slows the process of naturally produced CBN. When dried cannabis is crispy or completely brown, that could be a sign that it is older or was stored improperly, and may make you sleepy.
How is CBN different from CBD?
CBN is a different cannabinoid. CBN has stronger sedative properties than CBD. It has demonstrated anti-convulsant, appetite stimulation, and anti-inflammatory effects, especially when in the context of other cannabinoids. Adding CBN boosts the relaxing and sedative effects of CBD. Tetrahydrocannabinol (THC) can produce euphoric and sedating side effects. As a byproduct of THC degradation, cannabinol (CBN) retains the sedating effect without the euphoria. Some consumers prefer the less euphorigenic effects of CBN.
What else can I do? I hate not knowing if I'm going to sleep or lay awake all night.
I don't blame you--not knowing if you'll be able to sleep in itself stressful, and you're wise to avoid that!
There is a lot of research in the field of "sleep hygiene." Much of it is based on common sense methods of winding down. Make these tips habits or create some rituals for yourself.
As always, consult your health care provider before making any changes to your prescription medication.Wishing you the best in health!
Dr. June Chin
May 07th, 2020
Stress, Cannabis, Prescription Meds, Quarantine! How to balance it all ?
“Stress can make people feel like they are in a fog all the time or that everything is moving in slow motion. Sound familiar?
These days, most patients are contacting me for three reasons: 1) insomnia, 2) anxiety 3), and managing PTSD symptoms, all of which are stress related. So I thought it was a good time to address the relationship of COVID-19, stress and cannabis. When used correctly, cannabis can help put you in a relaxed state which makes it a key ally in fighting stress—and there are several biochemical reasons why this so. This blog is based on the most common questions I’m getting from my patients.
Why do I feel so out-of-focus? I was going to use some of this extra time to learn tap dancing and read Proust but I’ve never been less productive.
I’m not sure cannabis can help you finish Proust but it can certainly soothe your stress responses, which could encourage your productivity.
Intense trauma can temporarily rewire the body’s nervous system and trigger our sympathetic nervous system which activates our “flight or fight” response. Keeping up with COVID-19 can put your nervous system into a constant white-knuckled, holding-on-for-dear-life response. Hyperarousal means increased blood pressure and adrenaline. Short, fast breathing and heartbeat. Short-tempers and blown fuses. It can also cause people to re-experience traumatic memories that cause a vicious cycle of being too agitated to relax and too stressed to sleep. These changes can impair the immune system’s ability to respond to acute and chronic infections and can disrupt digestion, sleep, focus, and libido. It can also make people feel like they are in a fog all the time or that everything is moving in slow motion. Sound familiar?
But I haven’t been traumatized. I’m just constantly worrying about my health, my family’s health, the health of the economy.
You don’t have to be directly exposed to a traumatic event. Right now fear is more prevalent than the virus. Simply contending with overwhelming situations and information or sensory overload can affect some people so profoundly that they develop symptoms of PTSD. These symptoms can include:
· Sensitivity to light and sound
· Insomnia due to racing mind or trouble staying asleep
· Irritability and jumpiness
· Emotional sensitivity
· Heart racing/palpitations
· Blood pressure changes
· Digestive issues
Cannabis is a holistic, integrative plant medicine that can ease the body into a state of calm. When used correctly, it can:
· improve mood
· reduce anxiety
· promote restorative sleep
· suppress nightmares.
How can cannabis help anxiety and stress?
Did you know that our brains make their own internal cannabis molecules? It’s true. And one of them, anandamide (named after the Sanskrit word for bliss, ananda), helps temper stress and balance the nervous system, so we are not spiraling out of control on a high sympathetic overdrive.
Take, for example, forgetting. Forgetting is a crucial aspect of treating anxiety, stress, and PTSD. Trauma survivors have been found to have problems with neurotransmitter signaling of serotonin and glutamate, which also correlate with the fight-or-flight response. Excessive glutamate signaling will lock in painful fear-related memories. Cannabinoids can help release these painful memories by facilitating memory extinction. This helps survivors switch off those traumatic memories.
Here’s some deep chemistry to explain how this occurs. Cannabis mediates the neurotransmitter GABA (gamma-aminobutyric acid). GABA signals to our body that we are safe and directs the body to relax and power down. It helps to reduce anxiety, foster sleep, and relax the muscles. CBD and THC tell the brain to increase the flow GABA, which creates the quieting and calming effect. My patients report it works to“take the edge off and turn the volume on anxiety and stress way down. Once their racing thoughts and the “fight or flight” response tail off, patients say they feel better, “more comfortable in their own skin.” They can often quell racing thoughts that paralyze them at work or cause them to lie awake at night.
If you’re not an experienced cannabis user I recommend starting with CBD, which can ease the body into a state of “calm focus,” or very low amounts of THC in conjunction with CBD. Sometimes, just a few puffs on a vaporizer or no more than 2.5 mgs of THC will do the trick. You can always add more if you want more relief.
It seems that my girlfriend is responding to cannabis so much more strongly than me (I’m a guy). Are there gender differences?
Not only do women and men respond to cannabis differently, they also respond differently to PTSD yet almost no one is aware of this. Statistics show that women suffer twice as much PTSD as men but because the majority of the trauma research focuses on male combat veterans this is overlooked. According to the National Center for PTSD, around 10% of women have PTSD sometime in their lives compared to 4% of men.
Thanks to the hormone estrogen, women are more sensitive to the effects of the cannabinoids and terpenes in the plant. We experience several distinct physiological changes throughout our lives (pregnancy, menopause) that drastically alter the amount of estrogen in our system. Understanding how cannabis can help us regulate hormonal flux and ease these transitions can be a revelation for women interested in health and wellness. Estrogen makes women more sensitive to cannabis, primarily THC. THC and your hormones interact quite a bit so your cycle can influence your high.
Researchers at Washington State University found that women experience the effects of THC most powerfully when their estrogen has peaked and is beginning to fall. This happens a day or two before you ovulate. Preclinical studies have shown that the interaction between estrogen and THC makes women more sensitive to the compound in general, which is why they seem to get more benefit out of the herb as a chronic pain fighter than men.
My husband is so much more carefree than I am. He also uses more cannabis. What’s the relationship between high use and low stress?
Recent neuroscience research has shown that certain lucky people have a genetic variation in the brain that makes them inherently less anxious and more able to forget unpleasant experiences. These folks, whom you categorize as carefree, also have brains that produce higher levels of anandamide, the body’s own version of THC. Normal endocannabinoid system functioning helps people’s nervous systems to reset and re-calibrate more quickly after stress exposure. Researchers and clinicians agree that vulnerability to PTSD and resilience to stress are the result of an interaction between ECS, genes and environment.
How much cannabis should I use to keep my stress at bay?
That’s the big question with cannabis meds. Everyone’s endocannabinoid system is different and people’s experience with cannabis makes a difference when it comes to dosing. My15 years of treating patients with cannabinoid medicines have taught me that patients who are willing to experiment to create their own personal dosing regimen get the best results.
The "Start Low, Go Slow, Stay Low" dosing method begins with a CBD product, which you take in low doses (5-15 mgs) two to four times daily. You can increase the dose every 1 or 2 days until you feel relief. If you get no relief after a few weeks, try adding in a small amount (2.5 mgs of a tincture or a few vapor puffs) of THC to activate the CBD. Escalate your dose until you find relief. Inexperienced users may want to work with a health coach to get started. Experienced users will be more familiar with adjusting their doses to find optimal relief. The dosing guide below lists the average activation times and length of time effects will last. Refer to it until you are familiar with the timings.
Tips for Increasing Your Dose
After 3 or 4 dosing cycles, you’ll know if you need more relief. If you do, there are three ways of proceeding.
· Increase the amount of each dose of CBD
· Increase the frequency of dosing – i.e., go from twice a day to every four hours
· Add small amounts of THC to each dose of CBD and chart the effects.
The doses of THC in this method are very low and calibrated so that you don’t feel high. You may feel slightly elevated at first but you won’t feel out of control if you follow these guidelines. Any feelings of being altered will diminish after a few days. If it feels too strong, simply lower your dose of THC. Unless you are an experienced user we recommend not exceeding 5mg THC to start.
You’ll also learn what works best for you faster if you keep a record of how much you’re taking and how it’s making you feel. You can share this with your practitioner. The goal is to reduce symptoms without causing impairment, decreasing motivation, or increasing avoidance behaviors.
Other than using cannabis, what else can I do to calm myself immediately?
The other side of the sympathetic nervous system is the parasympathetic nervous system, which releases all sorts of chemicals to help us feel relaxed and safe. The parasympathetic system regulates our digestion, our connection to others and our sleep, which is the only time the body can repair itself. Cannabis helps to ease the body into the parasympathetic nervous system.
In her upcoming book, Good Chemistry, the psychopharmacologist Dr. Julie Holland lists a few things patients can do to flip from “fight or flight” into the “tend and befriend” mode. I’ve used some of these techniques with patients over the years and though they may sound simple, they work.
Breathe through your nose. Believe it or not, simply breathing through your nose for five or ten minutes can trigger the parasympathetic nervous system and snap you out of fight or flight. This is because taking shallow breaths through the mouth can trigger the sympathetic nervous system.
Balance the flow of negative thoughts. If you can’t stop thinking about how terrible things are at least give equal time to fantasizing about other things working out ok, or even well.
Sing, chant, or make music.
Swim or float on your back with your arms and legs wide. If you can get to a sensory deprivation tank where it’s dark and quiet, the body can stop paying attention to sensory input and the mind can be more free.
Havening. This is a self-soothing technique in which you cross your arms like you’re hugging yourself. There are plenty of videos online.
Do nothing. Put down your phone. Get off your screens. Focus on your breath or something in your field of vision. As Julie writes, “Try to be as fascinated by your breath as your Instagram feed. If you stop what you’re doing, sit down, pay attention to your breath instead of what you’re going to make for dinner, don’t tell anybody, but you’re meditating.”
Get out in nature. Cannabis helps connect you to your body and to the natural world. The vastness of natural world can help you put your concerns in perspective.
My patient who is 5 months pregnant and suffering from debilitating morning sickness with vomiting and nausea throughout the day, asked me "If you were pregnant, would you use cannabis?".
This is a question I get quite often.
My answer is that it all depends.
The benefits must outweigh the risks.
Every so often another scary piece about cannabis damaging the brains of babies and children crops up, just as it did in this piece in the New York Times: “Pregnant Women Turn to Marijuana, Perhaps Harming Infants”. The story pointed to several preliminary studies indicating that pregnant women who use cannabis risk having babies that are underweight and possibly cognitively impaired.
Dr. Stacey Kerr, physician and medical advisor to Hawaiian Ethos, a medical cannabis dispensary in Hawaii discussed this important topic with Medical Cannabis Mentor.
In utero development is not to be taken lightly, so it’s crucial to parse myth from fact. Of course, a pregnant woman should exercise caution when using any medication or substance that might affect the health of her baby as her blood is comingled with that of her fetus. But cannabinoids don’t function like other molecules and at this point, there’s a small, but growing amount of evidence that they might actually might further a baby’s development, or at least do no harm. It’s not the commonly expressed point of view, but it’s crucial to remember that most of the science in the US has been carried out by the National Institute of Drug Abuse, which has a mission to only investigate the harmful effects of the plant while ignoring the benefits. Twenty years ago, science assured us that the concept of medical marijuana was a joke. Yes, science, too, can change its collective mind.
Here’s what we know
The most prevalent cannabinoids found in cannabis, THC, and CBD, are bioidentical to two chemicals produced by the human brain, anandamide and 2AG. The next question is: Why does the brain produce these chemicals? What is their function?
The answer, in part, was offered by the late Dr. Ester Fride, an Israeli neuroscientist who was investigating the ways cannabinoids influence a newborn’s development. Her science showed that without a functioning endocannabinoid system newborn rats failed to suckle or begin maternal bonding. They died much sooner than babies with functioning endocannabinoid systems. Fride concluded that endocannabinoids are essential to a baby’s ability to thrive.
Equally compelling is the work Dr. Melanie Dreher, the Dean of Nursing at Rush Medical Center in Chicago. In the early 1990s Dreher traveled to Jamaica to investigate a group of rural and impoverished Rastafarian women and their infants. These “Roots Daughters” smoke ganja as a daily health ritual; they rely on it to maintain appetite, rest and allay nausea during pregnancy. They also serve a mild ganja tea to their families as a health tonic -- when you’re poor it’s less expensive to forestall illness than to treat it once it hits.
Dreher followed 30 Roots Daughters and their babies for five years until the children entered school. She found that infants whose moms smoked ganja socialized more quickly made eye contact more quickly, and were easier to engage than the babies of non-smokers. There were no developmental differences between the groups. In fact, on tests for verbal ability, motor, perceptual and quantitative skills, memory, and mood, the kids of smokers scored higher.
“Given what everyone else was finding at the same time, we thought [our findings] were pretty darned interesting and a little counterintuitive,” Dreher told me.
Though her findings were unprecedented they were published in 1994 to resounding silence. In the wake of that silence, Dreher applied to NIDA for additional funding to return to Jamaica to follow the same children at age 10 but her request was denied. Instead, NIDA continued to commission more studies from which researchers concluded that exposure to (extraordinary quantities of) cannabis in the womb might harm the brain, lower IQ, and damage “executive function.” Different variations on these dire warnings are still being trumpeted today.
Life Not Matching Research
Women throughout the world have been using cannabis as a natural medicine for centuries with no apparent harm, so for an alternate interpretation of the findings cited in the Times, I spoke to Dr. Stacy Kerr, a family physician and cannabis educator in Santa Rosa, CA. Dr. Kerr is one of the rare physicians who openly discusses her use of cannabis (probably because she works in a state that has had an operational medical marijuana program since 1996). “I grew up in the 1960s and we used cannabis when we were pregnant, and we were pregnant a lot,” Kerr, a mother of two, now in their 40s, tells me. “I delivered kids who were exposed in utero and watched them through childhood and into adulthood and I’m not seeing the results of these studies play out. I’m a physician and I want to believe these studies, but real life outcomes weren’t matching the research predictions.”
With the assistance of other researchers and a statistician, she examined the research most frequently quoted and found some notable discrepancies with the ways the samples were put together and the extrapolations of the findings.
In the studies of babies being born at lower weights, she discovered that all the women surveyed were asked if they had used any psychoactive substances (not specifically cannabis) and were also all from lower socio-economic backgrounds at a public hospital. Both factors could have influenced the results. She also points out, crucially, that there was no difference in the Apgar score, the measures the 5 key indicators of a baby’s health just after birth.
The other frequently quoted study by claims that kids of cannabis using moms do less well in life and are slower in school. But this research, according to Kerr, was skewed by factors other than prenatal exposure.
Are cannabinoids the same as other molecules?
The final claim is that prenatal exposure to THC somehow miswires the brain and impairs cognitive development. Indeed, endocannabinoids are active in the fetal brain. They help neurons grow in the correct direction and yes, using cannabis does add additional cannabinoids into to the equation, perhaps displacing those that occur naturally in the body. But there is no research to date showing that displacing those naturally occurring endocannabinoids is definitively problematic.
In fact, there is another study hinting that additional cannabinoids seem to somehow protect neural functioning. Those researchers looked a complex neural process called “global motion perception” that is damaged in kids with abnormal brain developments, such as autism or fetal alcohol syndrome. (Kids with impaired GMP are characterized as “seeing the trees but not the forest.” They see individual details in their field of vision but not the entire frame.) In addition, exposure to both cannabis and alcohol seemed to cancel each other out.
Kerr’s conclusion: “It’s not ‘drink alcohol and use cannabis and your baby will be just fine,’ but it is interesting that exposure to THC in brain improved this indicator of neural development.”
A question of intent
Clearly, the mystery of cannabinoids and pregnancy is yet to be solved. In the meantime, I asked Kerr if she were pregnant again if she’d use cannabis? To my surprise, she hesitated before answering.
“I hesitated because pregnant women today are going crazy -- there’s always another article on more that we can’t do, so for me, it comes back to intent and how you use cannabis as a medicine. If I am nauseated or in pain, or if I have a two-year-old who’s going crazy and making me so irritable that I’m yelling at the kids and my husband and if taking a puff relaxes me and makes me nicer then, sure, I’d use it.
“That said, there is also such a thing as cannabis abuse disorder so if a patient is using too much and the kids aren’t being fed or the house isn’t getting cleaned I’d think about it differently and advise them to stop.
“But making women afraid that something drastic is going to happen if they take a vapor hit or a puff on a joint based on the current science isn’t beneficial.”
The take-home message:
A pregnant woman should be careful when using any medication or substance that might affect the health of her baby because any time you give a medicine, the primary concern is how much of that medication gets passed through the placenta.
When you are pregnant, you should be abstaining from as many extraneous chemicals and toxins as possible. Our internal endocannabinoid system plays a critical role in modulating female and male reproductive systems and there is a whole galaxy of endocannabinoid receptors in the uterus, the ovaries, and the fallopian tube.
There are not enough long term studies related to CBD use and pregnancy or any human trials yet to make an evidence-based decision.
However, if your symptoms cannot be treated in any other way and you are endangering your baby by not getting enough nutrition and the benefits outweigh the risks, then CBD and cannabinoid medication can be an option.
As always, please consult your doctor before integrating medical cannabis as it can also interact with your current medications and supplements.