Sleep continuity, architecture and quality among treatment-seeking cannabis users: An in-home, unattended polysomnographic study

Genome-wide association studies of lifetime and frequency cannabis use in 131,895 individuals

Cannabis is one of the most widely used drugs globally. Decriminalization of cannabis is further increasing cannabis consumption. We performed genome-wide association studies (GWASs) of lifetime (N=131,895) and frequency (N=73,374) of cannabis use. Lifetime cannabis use GWAS identified two loci, one near CADM2 (rs11922956, p=2.40E-11) and another near GRM3 (rs12673181, p=6.90E-09). Frequency of use GWAS identified one locus near CADM2 (rs4856591, p=8.10E-09; r2 =0.76 with rs11922956). Both traits were heritable and genetically correlated with previous GWASs of lifetime use and cannabis use disorder (CUD), as well as other substance use and cognitive traits. Polygenic scores (PGSs) for lifetime and frequency of cannabis use associated cannabis use phenotypes in AllofUs participants. Phenome-wide association study of lifetime cannabis use PGS in a hospital cohort replicated associations with substance use and mood disorders, and uncovered associations with celiac and infectious diseases. This work demonstrates the value of GWASs of CUD transition risk factors.

How Biodegradable Polymers Can be Effective Drug Delivery Systems for Cannabinoids? Prospectives and Challenges

Cannabinoids are compounds found in and derived from the Cannabis plants that have become increasingly recognised as significant modulating factors of physiological mechanisms and inflammatory reactions of the organism, thus inevitably affecting maintenance of homeostasis. Medical Cannabis popularity has surged since its legal regulation growing around the world. Numerous promising discoveries bring more data on cannabinoids' pharmacological characteristics and therapeutic applications. Given the current surge in interest in the medical use of cannabinoids, there is an urgent need for an effective method of their administration. Surpassing low bioavailability, low water solubility, and instability became an important milestone in the advancement of cannabinoids in pharmaceutical applications. The numerous uses of cannabinoids in clinical practice remain restricted by limited administration alternatives, but there is hope when biodegradable polymers are taken into account. The primary objective of this review is to highlight the wide range of indications for which cannabinoids may be used, as well as the polymeric carriers that enhance their effectiveness. The current review described a wide range of therapeutic applications of cannabinoids, including pain management, neurological and sleep disorders, anxiety, and cancer treatment. The use of these compounds was further examined in the area of dermatology and cosmetology. Finally, with the use of biodegradable polymer-based drug delivery systems (DDSs), it was demonstrated that cannabinoids can be delivered specifically to the intended site while also improving the drug's physicochemical properties, emphasizing their utility. Nevertheless, additional clinical trials on novel cannabinoids' formulations are required, as their full spectrum therapeutical potential is yet to be unravelled.

Assessing changes in sleep across four weeks among adolescents randomized to incentivized cannabis abstinence

BACKGROUND

Withdrawal from cannabis use is associated with sleep disturbances, often leading to resumption of use. Less is known about the impact of abstinence on sleep in adolescence, a developmental window associated with high rates of sleep disturbance. This study investigated effects of sustained abstinence on self-reported sleep quality and disturbance in adolescents reporting frequent cannabis use.

METHODS

Non-treatment seeking adolescents, recruited from school screening surveys and the community, with frequent cannabis use (MAge=17.8, SDAge=1.7, 47% female, 45% non-white) were randomized to four weeks of biochemically-verified abstinence, motivated via contingency management (CB-Abst, n=53), or monitoring without an abstinence requirement (CB-Mon, n=63). A mixed-effects model was used to predict change in Pittsburgh Sleep Quality Index (PSQI) scores.

RESULTS

Participants in CB-Abst reported higher overall PSQI scores than those in CB-Mon (M=1.06, p=0.01) indicating worse sleep during the four-week trial. Sleep disruptions in CB-Abst increased during Week 1 of abstinence (d=0.34, p=0.04), decreased during Week 2 (d=0.36, p=0.04), and remained constant for the rest of the trial. At Week 4, sleep was comparable to baseline levels for those in CB-Abst (p=0.87). Withdrawal-associated sleep disruption in the CB-Abst group was circumscribed to increases in sleep latency (b=0.35; p=0.05).

CONCLUSIONS

Cannabis abstinence in adolescents was associated with transient delayed onset of sleep initiation falling asleep during the first week of abstinence. Findings highlight withdrawal-associated changes in sleep latency as an intervention target for supporting adolescents attempting abstinence. Future research should use objective measures of sleep and focus on elucidating mechanisms underlying sleep disturbances with cannabis use and withdrawal.

Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review

STUDY OBJECTIVES

To perform a qualitative scoping literature review for studies involving the effects of cannabis on sleep and sleep disorders.

METHODS

Two electronic databases, MEDLINE and EMBASE, searched for comprehensive published abstracted studies that involved human participants. Inclusion criteria were article of any type, published in English, a target population of cannabis users, and reported data on cannabis effect on sleep and sleep disorders. The Joanna Briggs Institute's (JBI) approach was elected as the methodology framework guidance in the scoping review process.

RESULTS

A total of 40 unique publications were found. The majority (82.5%) were from the Americas with 60% published in the last decade. Of the 40 studies, only 25% were randomized control trials, and the sleep outcome measurements were similar and comparable in only 20%. Cannabis users studied were reported either 73% frequent users or 27% sporadic users. The utilization of cannabis showed improved sleep (21%), worse sleep (48%), mixed results (14%), or no impact at all (17%) in the studies published in the last 5 decades.

CONCLUSIONS

Our findings summarize the lack of robust evidence to support the use of cannabis for sleep disorders. The varied cannabis user-related characteristics may account for the inconsistent results identified. Further studies assessing cannabis and sleep are needed to discern what works in what context, how it works, and for whom.

CITATION

Amaral C, Carvalho C, Scaranelo A, Chapman K, Chatkin J, Ferreira I. Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review. J Clin Sleep Med. 2023;19(5):975-990.

Assessing cognitive behavioral therapy for insomnia in individuals with cannabis use disorder utilizing actigraphy and serum biomarkers: A pilot study

OBJECTIVE/BACKGROUND

This pilot study aims to assess the effect of Cognitive Behavioral Therapy for insomnia (CBTi) in individuals with cannabis use disorder and insomnia. It also aims to investigate the effect of CBTi on levels of serum inflammatory markers in relation to insomnia symptoms.

METHODS/PATIENTS

Individuals with cannabis use disorder and insomnia symptoms were recruited over 18 months. Data collected included demographics, self-reported sleep parameters, and cannabis use. Blood samples were drawn to measure IL-2, IL-6, CRP, and cortisol. Participants completed the Insomnia Severity Index questionnaire (ISI) and the Patient Health Questionnaire-4 (PHQ-4), and they were provided with an actigraphy (wrist) device for 1 week before CBTi and a subsequent week after completing the 4 CBTi sessions.

RESULTS

Nineteen participants were enrolled in the study. The mean ISI score decreased from moderately severe insomnia at baseline to no clinically significant insomnia after CBTi with a sustained decrease at 3- and 6-months follow-up. Actigraphy showed a significant decrease in sleep onset latency (SOL) after CBTi. Three months after CBTi, 80% of participants reported a decrease in their cannabis use. There was also a significant and sustained decrease in mean PHQ-4 scores after CBTi. Although only trending towards significance, the levels of three out of four biomarkers (IL-2, IL-6, CRP) were decreased 6 months after CBTi.

CONCLUSIONS

CBTi is effective as a short- and long-term treatment of insomnia and comorbid anxiety/depression in individuals who regularly use cannabis. A potential added benefit is a reduction in cannabis consumption and inflammatory serum biomarkers.

Sleep as a Mediator Between Cannabis Use and Psychosis Vulnerability: A Longitudinal Cohort Study

Objectives

Increasing evidence implicates cannabis consumption as a key risk factor in the development of psychosis, but the mechanisms underpinning this relationship remain understudied. This study proposes to determine whether sleep disruption acts as a mediator of the cannabis-to-psychosis relationship.

Study Design

This longitudinal study assessed measures of cannabis use frequency, sleep quality (SQ), and psychotic-like experiences (PLEs) were collected using self-reported questionnaires. Data were collected from September 2012 to September 2018. Data were collected from a general population sample of adolescents who entered the seventh grade in 31 schools in the Greater Montreal area. The study uses data collected on an annual basis from 3801 high school students from grades 7 to 11. The aforementioned measures were measured using the Detection of Alcohol and Drug Problems in Adolescents questionnaire, a SQ Likert scale, and measures the Psychotic-Like Experiences Questionnaire for Children.

Study Results

Results show a reciprocal 1-year cross-lagged effect of cannabis use and sleep (β = -0.076, 95% CI = -0.037 to -0.018, P = .000), of sleep on cannabis use (β = -.016, 95% CI = -0.025 to -0.006, P = .007), of sleep on PLEs (β = -0.077, 95%CI = -0.014 to -0.051, P = .000), and of PLEs on sleep (β = -0.027, 95% CI = -0.037 to -0.018, P = .000). We additionally found a 2 years indirect lagged-effect of cannabis use on PLEs (β = 0.068, 95% CI = 0.024 to 0.113, P = .011) mediated by 1-year sleep (β = 0.006, 95% CI = 0.003 to 0.009, P = .001).

Conclusions

Our results suggest sleep disruptions simultaneously aggravate, and are aggravated by, cannabis addiction and PLEs. The longitudinal sleep-mediated effect of cannabis use on PLEs encourages further research into the role of sleep as a potential therapeutic target in the prevention of cannabis-related psychosis.

Recreational cannabis use is associated with poorer sleep outcomes in young adult African Americans

INTRODUCTION

The present study sought to determine the relationship between self-reported cannabis use dosage in grams per day with (1) objective sleep outcomes: sleep efficiency (SE), sleep onset latency SOL and number of night-time awakenings (NWAK) (2) if objective and subjective sleep measures, using the PSQI, differed between cannabis users and non-cannabis users.

METHODS

Our sample included 178 participants, aged 18-35 years. We collected demographic information, cannabis use in dosage per day and frequency of use, depressive symptoms through the CESD, and subjective sleep reports using the PSQI. After the survey assessment, we monitored sleep using the Phillips Actiwatch Spectrum watch for a minimum of 5 nights.

RESULTS

The amount of cannabis consumed per day was inversely related to SOL and SE, and positively related to NWAK. After controlling for covariates, regression models were statistically significant for predicting SOL (β = -0.369, p <.001), SE (β = -0.232, p <.05) and NWAK, (β = -0.318, p <.001), indicating cannabis dosage per day is the strongest predictor for the sleep parameters. Subjective sleep measures did not differ from cannabis users versus non-cannabis users.

CONCLUSION

Recreational cannabis use is beneficial for SOL but may be detrimental to SE as those who reported increased cannabis use also had more NWAK. Cannabis may be useful for sleep onset, results suggest that increased use does not aid in sleep maintenance.

Mood, sleep and pain comorbidity outcomes in cannabis dependent patients: Findings from a nabiximols versus placebo randomised controlled trial

BACKGROUND

Mood, sleep and pain problems are common comorbidities among treatment-seeking cannabis-dependent patients. There is limited evidence suggesting treatment for cannabis dependence is associated with their improvement. This study explored the impact of cannabis dependence treatment on these comorbidities.

METHODS

This is a secondary analysis from a 12-week double-blind placebo-controlled trial testing the efficacy of a cannabis agonist (nabiximols) against placebo in reducing illicit cannabis use in 128 cannabis-dependent participants. Outcome measurements including DASS-21 (Depression, Anxiety, and Stress subscales); Insomnia Severity Index (ISI); and Brief Pain Inventory (BPI), were performed at weeks 0, 4, 8, 12 and 24. Each was analysed as continuous outcomes and as binary cases based on validated clinical cut-offs.

RESULTS

Among those whose DASS and ISI scores were in the moderate to severe range at baseline, after controlling for cannabis use, there was a gradual decrease in severity of symptoms over the course of the trial. BPI decreased significantly until week 12 and then rose again in the post-treatment period during weeks 12-24. Neither pharmacotherapy type (nabiximols vs placebo) nor number of counselling sessions contributed significant explanatory power to any of the models and were excluded from the final analyses for both continuous and categorical outcomes.

CONCLUSIONS

Participants in this trial who qualified as cases at baseline had elevated comorbidity symptoms. There was no evidence that nabiximols treatment is a barrier to achieving reductions in the comorbid symptoms examined. Cannabis dependence treatment reduced illicit cannabis use and improved comorbidity symptoms, even when complete abstinence was not achieved.

Stimulants and Depressor Drugs in the Sleep-Wake Cycle Modulation: The case of alcohol and cannabinoids

A complex neurobiological network drives the sleep-wake cycle. In addition, external stimuli, including stimulants or depressor drugs, also influence the control of sleep. Here we review the recent advances that contribute to the comprehensive understanding of the actions of stimulants and depressor compounds, such as alcohol and cannabis, in sleep regulation. The objective of this review is to highlight the neurobiological mechanism engaged by alcohol and cannabis in sleep control.

Are Sweet Dreams Made of These? Understanding the Relationship Between Sleep and Cannabis Use

Introduction: There is widespread literature on the interaction between cannabis use and sleep, yet the mechanisms that underlie this relationship are not well understood. Several factors lead to inconsistencies in this relationship suggesting a nuanced interaction between cannabis and sleep. An important question that remains to be addressed is the temporal relationship between disrupted sleep and cannabis use. This literature review summarizes the existing literature on the association between disrupted sleep and cannabis toward the goal of addressing the question of the chronology of these reported effects. Materials and Methods: We conducted a review of the literature using PubMed to summarize current knowledge on the association between cannabis use and sleep in humans. Results: We identified 31 studies on the association of cannabis use and sleep. The findings from these studies were mixed. Cannabis was associated with a variety of impacts on sleep ranging from beneficial effects, such as reduced sleep-onset latency, to negative outcomes, such as reduced sleep duration and suppressed rapid eye movement oscillations. The chronology of the interaction of cannabis and sleep was unclear, although much of the current literature focus on factors that modulate how cannabis impairs sleep after initial use. Conclusion: There was sufficient evidence to suggest that cannabis use alters circadian rhythms, and hence, negatively impacts sleep. The current literature is largely from studies utilizing self-report measures of sleep; thus, objective measures of sleep are needed. In addition, although there were no empirical studies on the temporal relationship between cannabis use and sleep, the majority of the literature focused on characterizing sleep impairment after cannabis use.

Effects of Cannabinoids on Sleep and their Therapeutic Potential for Sleep Disorders

The recent trend for legalization of medicinal cannabis and cannabinoid-containing products, together with their soporific effects, has led to a surge of interest of their potential therapeutic role in the management of some common sleep disorders, such as insomnia, sleep disordered breathing, and restless legs syndrome, and less common disorders such as narcolepsy and parasomnias. Although much of the pre-clinical and clinical data were derived from studies with relatively small sample sizes and limited by biases in assessment, and in clinical trials lack of allocation concealment, as a whole, the results indicate a potential therapeutic role for cannabinoids in the management of some sleep disorders. Clinical trials are underway for insomnia and obstructive sleep apnea management, but there remains a substantial need for rigorous large multi-center studies to assess the dose, efficacy, and safety of the various types of cannabinoids on sleep disorders. This review aims to summarize the modulatory effects of cannabinoids on sleep physiology and provide a critical evaluation of the research on their potential therapeutic benefit in various sleep disorders.

Insomnia Symptoms among African-American Older Adults in Economically Disadvantaged Areas of South Los Angeles

BACKGROUND

Although psychosocial and health factors impact insomnia symptoms, less is known about these effects in economically disadvantaged African-American older adults.

AIMS

This study investigated social and health determinants of insomnia symptoms among economically disadvantaged African-American older adults.

METHODS

This survey enrolled 398 African-American older adults (age ≥ 65 years) from economically disadvantaged areas of South Los Angeles. Gender, age, educational attainment, financial difficulty, number of chronic diseases, self-rated health, pain intensity, and depression were covariates. Total insomnia, insomnia symptoms, and insomnia impact were our outcomes. Linear regression was applied for data analysis.

RESULTS

Based on linear regression, higher financial difficulty (B = 0.48, 95% CI = 0.35-0.61), smoking status (B = 1.64, 95% CI = 0.13-3.16), higher pain intensity (B = 0.39, 95% CI = 0.11-0.67), higher number of chronic diseases (B = 0.34, 95% CI = 0.05-0.64), and more depressive symptoms (B = 0.35, 95% CI = 0.12-0.57) were associated with a higher frequency of insomnia symptoms. Based on a logistic regression model, lower age (B = 0.91, 95% CI = 0.91-1.00) and high financial difficulty (OR = 1.15, 95% CI = 1.08-1.24), pain (OR = 2.08, 95% CI = 1.14-3.80), chronic disease (OR = 1.27, 95% CI = 1.07-1.51) and depression (OR = 2.38, 95% CI = 1.22-4.65) were associated with higher odds of possible clinical insomnia. We also found specific predictors for insomnia symptoms and insomnia impact.

CONCLUSIONS

Among African-American older adults in economically disadvantaged areas of South Los Angeles, insomnia symptoms co-occur with other economic, physical, and mental health challenges such as financial difficulty, smoking, multimorbidity, pain, and depression. There is a need to address sleep as a component of care of economically disadvantaged African-American older adults who have multiple social and health challenges.

The role of substance use, smoking, and inflammation in risk for suicidal behavior

BACKGROUND

Alcohol and substance use disorders are important predictors for suicidal behavior. However, the role of individual substances as proximal risk factors for suicidal behavior and the mechanisms through which substance use affect risk are not entirely clear. We examine whether the frequency of substance use and whether biological markers in the HPA axis and inflammatory pathways are associated with clinical risk factors of suicidal behavior of aggression, impulsivity, hopelessness, and poor sleep.

METHODS

The sample consisted of psychiatric inpatients, aged 15-30 years, admitted for suicide attempt (n = 38), suicidal ideation (n = 40); and healthy controls (n = 37). We measured hair cortisol concentrations, glucocorticoid receptor (GR) sensitivity, stimulated production of interleukin- or IL-6, C-reactive protein, and mRNA expression of GR, SKA2, FKBP5, TNF-α, and IL-1β.

RESULTS

Smoking was associated with increased aggression [β = 2.9, 95% CI (-0.03, 6), p = 0.05], impulsivity [β = 3.1, 95% CI (1.6, 4.6), p < 0.001], and poor sleep [β = 0.5, 95% CI (0.03, 0.95), p = 0.04] even after controlling for demographics and group. Similarly, TNF-α mRNA was associated with impulsivity [β = 0.07, 95% CI (0.01, 0.1), p = 0.02] and hopelessness [β = 0.03, 95% CI (0.004, 0.05), p = 0.03]. Smoking tobacco (r = 0.32, p < 0.001) was positively associated with TNF-α mRNA.

LIMITATIONS

Study limitations include the cross-sectional design, retrospective assessment, and relatively small sample size.

CONCLUSIONS

Future longitudinal studies are needed to test whether inflammatory markers mediate the relationships between smoking, clinical risk factors, and suicidal behavior; and to examine whether smoking cessation could reduce the risk for suicidal behavior in at-risk patients.

Online cognitive behavioral therapy for insomnia (CBT-I) for the treatment of insomnia among individuals with alcohol use disorder: study protocol for a randomized controlled trial

Abstract

Alcohol use disorder (AUD) is characterized by problematic drinking that becomes severe. Individuals with AUD often experience insomnia and other sleep disturbances at various phases of recovery. Cognitive behavioral therapy for insomnia (CBT-I) is an efficacious non-pharmacological treatment for insomnia and is recommended as a first-line treatment for adults with chronic insomnia. Internet-based CBT-I could play a key role in the dissemination of this behavioral sleep intervention, given the paucity of trained clinicians able to provide CBT-I in person and other logistical/cost concerns. SHUTi (Sleep Healthy Using The Internet) is the most tested and empirically-sound Internet intervention for insomnia. Despite the promise of Internet-based CBT-I interventions, to date, no randomized controlled trials (RCTs) exist examining the feasibility/efficacy of an Internet-based CBT-I program among treatment-seeking individuals recovering from AUD. This is a two-phase RCT assessing feasibility/acceptability and efficacy of the SHUTi program among individuals with AUD in recovery with insomnia. Phase I will focus on assessing the feasibility and acceptability of program delivery and data collection (n = 10). Phase II will be an RCT powered to examine preliminary intervention efficacy (n = 30 per group). Participants for this study must meet criteria for “moderate to severe” insomnia. Individuals randomized to the intervention group will receive the SHUTi intervention (initiated while inpatient and completed while outpatient), and individuals randomized to the control group will receive an educational web-based program. The goals of the study are as follows: (1) assess the feasibility and acceptability of Internet-based CBT-I among individuals with AUD in recovery with insomnia (phase I), (2) compare the preliminary efficacy of CBT-I versus control group with respect to primary and secondary outcome variables (phase II), and (3) explore specific domains associated with improved outcomes, e.g., demographic, psychiatric, and drinking-related factors (phase II). Primary outcome measures include changes in insomnia severity over time and changes in actigraphy-recorded sleep efficiency over time.

Trial registration

NCT#03493958; registered 1 June 2018.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0376-3) contains supplementary material, which is available to authorized users.

Sleep Management Among Patients with Substance Use Disorders

Sleep and substance use disorders commonly co-occur. Insomnia is commonly associated with use and withdrawal from substances. Circadian rhythm abnormalities are being increasingly linked with psychoactive substance use. Other sleep disorders, such as sleep-related breathing disorder, should be considered in the differential diagnosis of insomnia, especially in those with opioid use or alcohol use disorder. Insomnia that is brief or occurs in the context of active substance use is best treated by promoting abstinence. A referral to a sleep medicine clinic should be considered for those with chronic insomnia or when another intrinsic sleep disorder is suspected.

Exploring Interventions for Sleep Disorders in Adolescent Cannabis Users

This review summarizes the available literature on the intersection of adolescent cannabis use and sleep disturbances, along with interventions for adolescent cannabis users who suffer sleep impairments. Adolescents are susceptible to various sleep disorders, which are often exacerbated by the use of substances such as cannabis. The relationship between cannabis and sleep is bidirectional. Interventions to improve sleep impairments among adolescent cannabis users to date have demonstrated limited efficacy, although few studies indicating the benefits of behavioral interventions-such as Cognitive Behavior Therapy for Insomnia or Mindfulness Based Stress Reduction-appear promising in the treatment of sleep disorders, which are present for users of cannabis. Further research is necessary to elucidate the precise mechanisms by which cannabis use coexists with sleep impairments, along with effective interventions for those users who suffer sleep difficulties.