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Insomnia is a very common issue for many patients with an estimated 50 to 70 million Americans experiencing chronic symptoms. It causes issues hindering daily functioning and adversely affects health and longevity. Symptoms include one or more of the following: excessive daytime sleepiness, difficulty in falling or staying asleep, poor quality (not restful) sleep, early morning awakening and/or abnormal events occurring during sleep. In addition, patients will experience daytime impairment related to sleep difficulty: issues with attention, concentration, or memory; concerns or worries about sleep; daytime sleepiness; errors at work or accidents while driving; fatigue or malaise; gastrointestinal symptoms; lack of motivation; mood disturbance or irritability; social, or poor work/school performance; or tension headaches.

It can occur as a primary complaint (there are approximately 90 distinct sleep disorders) or in association with other conditions. The long term effects of sleep loss are associated with a wide range negative effects, increasing the risk of high blood pressure, diabetes, obesity, depression, heart attack and stroke. Insomnia may be a feature of some psychological disorders and poor sleep makes many psychiatric conditions worse. It contributes to the severity of chronic pain symptoms. Improving sleep improves overall health as well as improving symptoms of other conditions for which poor sleep contributes to the severity of symptoms.

Sleep Hygiene

The easiest therapy to implement and one which should first be used is proper sleep hygiene. If this technique is very effective, it will the only treatment required. If other treatment is required, it is important to continue good sleep hygiene practices to optimize results of the added treatments.

Good sleep hygiene includes behavioral and environmental factors. Keeping a regular schedule will train your brain and body to get used to getting the amount of sleep you need. Try to allot eight hours for sleep and schedule your bed time based on your usual wake time. Allow a half hour to wind down and relax before retiring. Listening to music, reading, mediating- whatever activity puts you in a chill mood. Avoid using any video screens, the blue light tones emitted can disrupt sleep. You should get in the habit of retiring for sleep at the same time every night. Having a regular, fixed bed time and wake up time, weekday or weekend, will train your body into having a structured sleep rhythm. Keep a regular sleep schedule.

Avoid excessive alcohol. Although it can helping fall asleep, it can disrupt sleep as it wears off. Caffeine is a stimulant drug and foods and beverages containing it should be avoided in the evenings. Consuming a large meal late in the evening can disrupt sleep, so eat early.

Consider your bedroom as the place exclusively for sleep with the exception of sex. This builds a connection in your brain between being in bed and sleep. You bedroom should be comfortable, dark and quiet. You may consider blackout shades or an old school eye mask in light is a problem. A quiet environment is best for sleep. Leave the television and radio off. A fan or white noise generator can cover intrusive noise or ear plugs can be used if other measures are not effective.

If you have been practicing good sleep hygiene, but have not achieved an adequate response, medications can be considered.

Medications for Insomnia

Many prescription drugs drugs are used to treat insomnia. Benzodiazepine medications, like Valium, Klonopin and Xanax are sedating and are often prescribed for insomnia. They can be very effective in the short term, but there effectiveness tends to fade over time. Dependency on this class of drugs occurs and abrupt discontinuation can result in drug withdrawal symptoms. Antidepressants, antihistamines and sometimes antipsychotic medications, all of which have sedating and other sometimes have other detrimental side effects, are often prescribed. The so called “Z” drugs like Ambien and Lunesta developed specifically for insomnia are effective for short term use, but bring in their own side effect issues like sleep walking and sleep driving with no memory of the events. Most patients using these medications will become tolerant to them over time, requiring higher doses to be effective which increases the possibility and severity of deleterious side effects. Decreased alertness the next morning, a hangover effect and sometimes impairment of driving/work skills happen to some patients. Many patients being treated with these medications will find that they are unable to achieve any quality sleep without using them and become dependent on them for sleep.

Over the counter sleep aids are usually antihistamine based and are of modest efficacy. They often have side effects including a hangover which limits their use. Melatonin is a naturally produced hormone the brain produces in response to light; less light means more melatonin. It is involved is setting your brain’s internal clock and wake/sleep patterns. Although it can help some patients sleep, melatonin can cause hangovers and poorly timed doses may result in detrimental changes to the sleep cycles.

Many patients who achieve inadequate results practicing good sleep hygiene and have side effects or poor responses to the usual medications continue to suffer symptoms and continued degradation of their health. An alternative option for patients to consider is cannabis.

Cannabinoids for Insomnia

Tetrahydrocannabinol (THC) can be used to treat insomnia. THC is interesting in that low to moderate doses tend to be stimulating whilst higher doses are sedating. If using THC for insomnia, you will need to be at the higher dose ranges. You need to “get stoned” for it to be effective. I usually suggest flower by smoking or dry herb vaporization at bed time. Strains containing sedating terpenes like linalool and myrcene will be more effective. If you wake in the middle of the night, just repeat the dose. Inhalation allows easy titration to an effective dose allowing patients to fall asleep and last a short enough time to make hang over effects less likely. Edibles can be used but are unpredictable as when the effects will begin, how intense they will be and how long they will last, making them complicated for many patients to properly dose. THC tinctures are better absorbed and are much more reliable in the produced effects, making them a better choice for patients wishing to avoid inhalation.

Cannabidiol (CBD) can help with insomnia, although in my experience with patients, it is more effective at maintaining sleep than inducing sleep. Sublingual (under the tongue) tinctures are the preferred method of consumption for the relatively fast onset and predictability of effects. CBD tinctures administered with THC tinctures can provide assistance with falling asleep (THC) and staying asleep (CBD).

Cannabinol (CBN) is the end degradation product of THC. It does not produce any euphoric effects (high) but is sedating to the majority of patients. As with many of the “minor” cannabinoids, new production techniques have made “isolates” (100% CBN) of the drug available. Usually administered as a sublingual tincture (most commercial preparations contains a mix of CBN and CBD) at bedtime, it can be an effective treatment for insomnia. These tinctures seem to provide a longer effect than just THC and are less likely to produce a “hangover” effect.

Terpenes for Insomnia

When selecting flower for treating insomnia, terpene considerations are important. Avoid flower with high levels of pinene and limonene (“Sativa” terpenes) as these will be stimulating. Linalool and myrcene (“Indica terpenes) dominant strains are more are relaxing and sedating making them a better choice.

Insomnia Wrap Up

Smoking flower is the easiest method to treat insomnia using THC. Using a sedating strain containing myrcene and/or linalool such as Glueball or Gorilla Glue at the higher dose range is effective for many patients, particularly for those with issues of falling asleep. It lasts a shorter period of time than the other suggestions and is unlikely to produce hangover effects.

THC tinctures are reliably absorbed and tend to be intermediate between inhalation and edibles in effect length. A higher dose range will be required to be sedating compared to what is used to control other symptoms during the day. Consuming a light meal contain fats prior to using the tincture will aid absorption of the swallowed cannabinoids contributing to the loner lasting effects.

Edibles of THC are effective for insomnia but the variability in absorption and long lasting potent effects of the 11-OH-THC metabolite produced by the liver after ingestion results in difficult to predict results and the possibility of hangover effects. Consuming fat prior to using the edible will improve absorption.

CBD in the higher dose ranges can help with patients that have difficulty staying asleep but is variably effective in helping patients fall asleep. Some CBD tinctures combine essential oils and terpenes in their products to improve effectiveness.

Although research is currently indeterminate as to the effectiveness of CBN for insomnia, a majority of patients I have suggested it to find it sedating and useful for treating this disorder. CBN tinctures should be used with CBD tinctures with a CBD dose 2-3 times that of CBN. Most patients respond to a 3.0mg-5.0mg CBN dose 30 minutes SL before retiring although I have a few patients who require 10mg doses.