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. Author manuscript; available in PMC: 2018 Nov 1.
Published in final edited form as: Drug Alcohol Depend. 2017 Sep 9;180:227–233. doi: 10.1016/j.drugalcdep.2017.08.017

Prevalence and correlates of sleep-related problems in adults receiving medical cannabis for chronic pain

James A Cranford 1, J Todd Arnedt 1, Deirdre A Conroy 1, Kipling M Bohnert 1,2, Carrie Bourque 1, Frederic C Blow 1,2, Mark Ilgen 1,2
PMCID: PMC5648597  NIHMSID: NIHMS905248  PMID: 28926791

Abstract

Purpose

To examine the prevalence and correlates of sleep problems in a sample of medical cannabis patients.

Procedures

Adults ages 21 and older (N = 801, M age = 45.8) who were seeking medical cannabis certification (either for the first time or as a renewal) for chronic pain at medical cannabis clinics in southern Michigan completed baseline measures of cannabis use, sleep, pain, and other related constructs.

Findings

Over half of the sample (59%) met criteria for past 1-month sleep disturbance, defined as at least one sleep problem occurring on 15 or more nights in the past month. Most participants (86%) reported that sleep problems were due to their current pain. Approximately 80% of participants reported using cannabis in the past 6 months to improve sleep and, among these participants, cannabis was rated as helpful for improving sleep. Sleep-related cannabis side effects were rare (35%), but sleep-related cannabis withdrawal symptoms were relatively common (65%). Statistically significant correlates of past 1-month sleep disturbance included a) being female, b) being white, c) being on disability, d) not having a medical cannabis card, and e) frequency of using cannabis to help sleep.

Conclusions

Sleep problems are highly prevalent and frequent in medical cannabis patients and are closely tied to pain. Sleep-related cannabis withdrawal symptoms are relatively common but their clinical relevance is unknown. The association between frequency of cannabis use to help sleep with higher odds of sleep problems will need to be clarified by longitudinal studies.

Keywords: medical cannabis, sleep, sleep disturbance, pain, correlates of sleep disturbance

1. Introduction

As of July 2017, twenty-nine US states and the District of Columbia have passed legislation legalizing cannabis for medicinal purposes (National Conference of State Legislatures, 2017). Epidemiological evidence has indicated that, among past-year cannabis users, about 10% reported using cannabis for medical reasons (Compton et al., 2017); among past-year cannabis users living in states where medical cannabis has been legalized, 17% reported using for medical reasons (Lin et al., 2016). The rapidly changing epidemiology of medical cannabis highlights the importance of research on the potential beneficial and adverse effects of cannabis use (Volkow et al., 2017). Although a long line of research has established associations between recreational cannabis use and adverse health outcomes (Wilkinson et al., 2016), the relationship between cannabis use and sleep appears to vary as a function of dose and timing of administration (Babson and Bonn-Miller, 2014; Conroy and Arnedt, 2014). Evidence indicated that cannabis has sedative and excitatory effects (Babson and Bonn-Miller, 2014), and cannabis withdrawal is associated with sleep disruptions (Bolla et al., 2010; Gates et al., 2016). One study showed that heavy (but not occasional) cannabis use was associated with sleep disturbance (Conroy et al., 2016).

Despite these potential adverse effects, emerging evidence indicated that cannabis is commonly sought as a sleep aid (Ferguson and Ware, 2015). For example, Bohnert et al. (under review) found that, among a sample of adult medical cannabis patients, sleep was the most highly endorsed motive for use on the Comprehensive Marijuana Motives Questionnaire (CMMQ). About 48% of participants recruited from a dispensary in California sought medical cannabis for insomnia (Bonn-Miller et al., 2014a), and a recent meta-analysis found low-quality evidence that medical cannabinoids were associated with better sleep outcomes (Whiting et al., 2015). Similarly, a recent report from the National Academies of Sciences concluded that there is “moderate” evidence to support that “cannabinoids…are an effective treatment to improve short-term sleep outcomes in individuals with sleep disturbance associated with obstructive sleep apnea syndrome, fibromyalgia, chronic pain, and multiple sclerosis” (NAS, 2017, p. 115). Some evidence from polysomnography (PSG) studies also showed that cannabis was associated with shorter sleep latency and increases in slow-wave sleep (Angarita et al., 2016).

These encouraging findings are tempered by concerns that chronic cannabis use could lead to increases in cannabis use disorders (Babson et al., 2017; Benbadis et al., 2014), exacerbation of sleep problems (Babson and Bon-Miller, 2014), and other adverse outcomes (D’Souza and Ranganathan, 2015). For example, using marijuana for sleep-related motives was correlated to greater frequency of use and marijuana-related problems among nonmedical cannabis users (Lee et al., 2009), and using cannabis to improve sleep was associated with higher frequency of cannabis use among medical users with probable PTSD (Bonn-Miller et al., 2014b). There is also evidence that cannabis withdrawal has negative effects on self-reported and PSG measures of sleep (Angarita et al., 2016; Babson et al., 2017; Benbadis et al., 2014).

Although a growing body of evidence indicates strong bidirectional associations between substance use and sleep (Conroy and Arnedt, 2014; Arnedt et al., 2007), those who are seeking medical cannabis are an understudied and distinct group of individuals, and little is known about their sleep and patterns of cannabis use. In the state of Michigan, where the current research was conducted, the Michigan Medical Marihuana Act passed in 2008 legalized the use of cannabis for the treatment of debilitating medical conditions (e.g., cancer, glaucoma, severe or chronic pain). Qualifying patients or primary caregivers are required to obtain a registry identification card through a state registry program. As of January 2016, 182,091 patients and 34,269 caregivers have been approved for medical cannabis registry identification cards in Michigan (Gaedeke, 2016). In this research, we aimed to extend our knowledge about sleep-related problems among medical cannabis users with chronic pain. The two primary aims of this work were to 1) determine the prevalence of sleep-related problems and sleep-related cannabis use in medical cannabis users with chronic pain, and 2) identify the demographic and cannabis use correlates of sleep-related problems in medical cannabis users with chronic pain.

2. Methods

2.1. Participants

This paper is based on a larger project that is designed to identify patterns of cannabis use in medical cannabis patients with chronic pain in the state of Michigan. Adult patients (≥ 21 years old) attending a medical appointment for certification or recertification for a state medical cannabis card were eligible for screening. Patients were approached by trained research assistants (RAs) in clinic waiting areas. RAs provided a brief overview of the study and obtained written informed consent for screening. Consenting participants completed a 15 to 30-minute self-administered screening survey, and their responses were used to determine study eligibility. Inclusion criteria were: self-report of pain in the past month, of at least “usual pain” 5 or greater on a 0–10 numeric rating scale (NRS; Farrar et al., 2001), and self-reported chronic pain as a medical reason for seeking medical marijuana. Additional exclusion criteria were: seeking medical cannabis for Alzheimer’s disease or cancer, and women who reported that they were pregnant. Of the 2,569 patients who presented to the study sites during the recruitment period, a total of 1,485 participants (58%) completed the screening survey. Of the 1,485 participants who completed the screening survey, a total of 801 participants (54%) met eligibility criteria, agreed to participate in the study, and completed the baseline questionnaire. Participants were financially compensated for completing the screening and baseline surveys. A previous report based on this project (Cranford et al., 2016) used data from the larger screening sample (N = 1,485). The current paper focuses on the baseline sample (N = 801) because that survey included expanded assessments related to sleep.

2.2. Measures

2.2.1. Demographics

included questions about sex, race/ethnicity, education (highest grade completed in school), current marital status, and current employment status, whether the participant was a first-time or returning patient (assessed with an item asking if the participant currently had a medical marijuana card), and reasons for seeking medical marijuana.

2.2.2. Sleep Disturbance in the Past Month

was assessed with the Jenkins Sleep Problems Questionnaire (Jenkins et al., 1988), which includes four items asking about frequency of a) trouble falling asleep; b) waking up several times per night; c) trouble staying asleep; and d) waking up feeling tired and worn out. A sample item is “How often in the past month did you wake up several times per night?” Response options for each item were: 0 = Not at all, 1 = 1–3 days, 2 = 4–7 days, 3 = 8–14 days, 4 = 15–21 days, 5 = 22–31 days. Based on previous research (Lallukka et al., 2011), we classified participants who reported any of the four sleep problems occurring on 15 or more nights during the past 1 month as having a sleep disturbance.

2.2.3. Frequency of Past 6-Month Medical Cannabis

was assessed with the question “In the past 6 months, how often have you used marijuana for a medical reason?” Response options were: 0 = I have not used marijuana for a medical reason in the past 6 months, 1 = Very seldom, 2 = Less then weekly, 3 = 1–2 days/week, 4 = 3–7 days/week, 5 = Several times a day.

2.2.4. Average Quantity of Weekly Cannabis Use in the Past Month

was assessed with the question “During the past month, on average, how much marijuana (for medical or non-medical use) did you use per week?” Response options were: 0 = None, 1 = Less than an eighth of an ounce, 2 = An eighth to slightly less than a quarter of an ounce, 3 = A quarter to slightly less than a half of an ounce, 4 = A half to slightly less than one ounce, 5 = One or more ounces.

2.2.5. Duration of Cannabis Intoxication on an Average Day in the Past Month

was assessed with the question “During the past month, how many hours, on an average day, do you feel high or stoned?” Response options were: 1) 0 hours, 2) 1–2 hours, 3) 3–4 hours, 4) 5–6 hours, 5) 7–8 hours, 6) 9 or more hours.

2.2.6. Pain-Related Sleep Problems

were measured with items adapted from Hendler et al. (1979; also see Hendler et al., 1988). “These items ask about your current pain condition. Do you ever have trouble falling asleep or awaken from sleep?” Response options were: 0 = No and 1 = Yes. An affirmative response to this item led to two more questions: “How often do you have trouble falling asleep due to your pain?” Response options were 0 = I do not have trouble falling asleep, 1 = I have trouble falling asleep which is not related to pain, 2 = Rarely, 3 = More than 3 times per week, 4 = Every night, 5 = Multiple times a night. “How often do you awaken from sleep due to your pain?” This question had the same response options with the exceptions: 0 = Never, and 1 = I have restless sleep or early morning awakenings with or without being able to return to sleep that are not related to pain. In addition, an item from the Back Pain Functional Scale (BPFS; Stratford et al., 2000) asked “Today, do you or would you have any difficulties at all with the following activities because of pain? Sleep.” Response options were: 0 = Unable to perform activity, 1 = Extreme difficulty, 2 = Quite a bit of difficulty, 3 = Moderate difficulty, 4 = A little bit of difficulty, 5 = No difficulty.

2.2.7. Cannabis Use for Sleep Problems

Three items from the Comprehensive Marijuana Motives Questionnaire (CMMQ; Lee et al., 2009) asked about frequency of using cannabis in the past 6 months: 1) to help you sleep, 2) because it makes napping easier and more enjoyable, and 3) because you are having problems sleeping. Response options were: 1 = Almost never/Never to 5 = Almost always/Always. Also, as part of a longer assessment of cannabis use for symptom relief, participants were asked if they had used cannabis in the past 1 month “to improve your sleep.” Those who responded affirmatively were then asked “during the past month, on average, how helpful was marijuana in improving your sleep?” Response options were: 0 = Not at all to 10 = Very helpful.

2.2.8. Sleep-Related Cannabis Side Effects

Participants were also asked if they had experienced a) insomnia or b) drowsiness during the past 6 months as a result of using cannabis or prescription pain medication.

2.2.9. Sleep-Related Cannabis Withdrawal Symptoms

were assessed with two items from the Marijuana Withdrawal Checklist (Budney et al., 1999) that asked about the experience and severity of a) sleep difficulty, and 2) strange dreams “the last time you went a significant time without using marijuana.” Response options were: 0 = None, 1 = Mild, 2 = Moderate, 3 = Severe. Also, we included one item adapted from the Patient Health Questionnaire (PHQ-9; Kroenke and Spitzer, 2002) that asked “Over the last 2 weeks (when you have not been using marijuana), how often have you been bothered by trouble falling or staying asleep, or sleeping too much?” Response options were: 0 = Not at all, 1 = Several days, 2 = More than half the days, 3 = Nearly every day.

2.3. Statistical Analysis

To address our research questions, we calculated descriptive statistics and estimated the prevalence of past 1-month sleep disturbance. Correlates of sleep disturbance were tested with bivariate and multiple logistic regression analysis (Agresti, 2013). The multiple logistic regression analysis included eight covariates that were statistically significant correlates of sleep disturbance at the bivariate level. This analysis used listwise deletion of missing data and included n = 701 cases (87.5% of the cases with data on past 1-month sleep disturbance). The alpha level for all analyses was set at .05.

3. Results

3.1. Demographics and Cannabis Use Variables

As seen in Table 1, participants had a mean age of 45.8 years, were roughly evenly distributed by sex, and were mostly (86%) white. Most participants (66%) reported “at least some college” and 54% were married or in a long-term relationship, about 41% were currently employed, and most (66%) were returning medical cannabis patients. Per our inclusion criteria, all participants reported seeking medical cannabis for “severe and chronic pain” with a usual past 1-month pain level of 7.1 on the NRS, and the other most frequently endorsed reason for seeking medical cannabis was for “severe and persistent muscle spasms” (29%). By comparison, the top two reasons for seeking medical cannabis in the state of Michigan during 2015 were “severe and chronic pain” (93%) and “severe and persistent muscle spasms” (23%) (Gaedeke, 2016). About 41% of participants reported medical cannabis use multiple times per day during the past 6 months, more than half indicated consuming ¼ ounce or more of cannabis during an average week, and about 50% of participants report feeling intoxicated for 3 hours or more on an average day in the past 1 month.

Table 1.

Demographic, Pain, and Cannabis Use Variables at Baseline (N = 801)1

N (%) or Mean (SD)
Age 45.8 (12.8)
Gender
  Female 383 (48%)
  Male 417 (52%)
  Transsexual 1 (0.1%)
Race/Ethnicity
  African American 90 (11%)
  White 686 (86%)
  Other 25 (3%)
Education
  Some college/College graduate 527 (66%)
  Less than high school/High school graduate 274 (34%)
Marital Status
  Married or long-term relationship 429 (54%)
  Divorced/separated/widowed 184 (23%)
  Never married 177 (22%)
Employment Status
  Work full-time or part-time 325 (41%)
  Disability 271 (34%)
  Retired 85 (11%)
  Unemployed 63 (8%)
  Other 45 (6%)
Usual Pain During the Past 1 Month 7.1 (1.4)
Currently Have a MMJ Card
  Yes 520 (66%)
  No 272 (34%)
Past 6 Month Frequency of Marijuana Use for Medical Reasons
  No past 6-months medical use 65 (8%)
  Very seldom 34 (4%)
  Less than weekly 22 (3%)
  1–2 days a week 65 (8%)
  3–7 days a week 280 (35%)
  Several times a day 328 (41%)
Past 1 Month Avg. Quantity of Cannabis Use per Week
  None 69 (9.0%)
  Less than 1/8 of an oz. 130 (17%)
  1/8 to slightly less than ¼ of an oz 156 (20%)
  ¼ to slightly less than ½ of an oz 179 (23%)
  ½ to slightly less than 1 oz 122 (16%)
  One or more ounces 115 (15%)
Past 1 Month Number of Hours Felt High or Stoned on Avg. Day
  0 hours 98 (14%)
  1–2 hours 262 (37%)
  3–4 hours 191 (27%)
  5–6 hours 78 (11%)
  7–8 hours 41 (5%)
  9 or more hours 45 (6%)
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1

Due to missing data and panned missingness, Ns ranged from 715 to 801. Percentages do not always add to 100% due to rounding.

3.2. Prevalence of Past 1-Month Sleep Problems and Sleep Disturbance

Descriptive statistics for the individual sleep disturbance items are presented in Table 2. Results showed that the most frequent sleep problem was waking up several times at night (M = 3.0), followed by having trouble staying asleep (M = 2.6), waking up feeling tired and worn out (M = 2.6), and having trouble falling asleep (M = 2.4), F (3, 2349) = 36.5, p < .05. As shown in Table 2, it is notable that 30% of the sample reported waking up several times at night on at least 22 days during the previous month, and over half of the sample (59%) were classified as having past 1-month sleep disturbance. Results in Table 2 also show descriptive statistics for pain-related sleep variables. About 86% of participants reported ever having sleep problems due to their current pain; about the same proportion expected to have at least “moderate” difficulty sleeping today because of pain, and roughly 30% of participants indicated that their pain-related sleep problems occurred every night and/or multiple times per night.

Table 2.

Sleep-Related Variables at Baseline1

N (%) or Mean (SD)
How often in past 1 month did you…
1. Have trouble falling asleep?
  Not at all 146 (18%)
  1–3 days 158 (20%)
  4–7 days 111 (14%)
  8–14 days 123 (16%)
  15–21 days 115 (14%)
  22–31 days 143 (18%)
2. Wake up several times per night?
  Not at all 82 (10%)
  1–3 days 121 (15%)
  4–7 days 126 (16%)
  8–14 days 117 (15%)
  15–21 days 109 (14%)
  22–31 days 238 (30%)
3. Have trouble staying asleep?
  Not at all 129 (16%)
  1–3 days 139 (18%)
  4–7 days 117 (15%)
  8–14 days 107 (13%)
  15–21 days 116 (14%)
  22–31 days 187 (24%)
4. Wake up feeling tired and worn out?
  Not at all 129 (16%)
  1–3 days 139 (17%)
  4–7 days 117 (15%)
  8–14 days 132 (17%)
  15–21 days 133 (17%)
  22–31 days 148 (19%)
5. Past 1 Month Sleep Disturbance2
  Yes 472 (59%)
  No 326 (41%)
6. Ever have trouble falling asleep/awaken from sleep related to current pain?
  Yes 666 (86%)
  No 106 (14%)
7. How often do you have trouble falling asleep due to your pain?
  I do not have trouble falling asleep 25 (4%)
  I have trouble falling asleep/not pain-related 68 (10%)
  Rarely 90 (14%)
  More than 3 times per week 267 (40%)
  Every night 135 (20%)
  Multiple times a night 79 (12%)
8. How often do you awaken from sleep due to your pain?
  Never 15 (2%)
  I have restless sleep that is not pain-related 79 (12%)
  Rarely 121 (18%)
  More than 3 times per week 247 (37%)
  Every night 104 (16%)
  Multiple times a night 99 (15%)
9. Today, do you or would you have any difficulties at all with SLEEP because of pain?
  No difficulty 86 (11%)
  A little bit of difficulty 132 (17%)
  Moderate difficulty 168 (21%)
  Quite a bit of difficulty 189 (24%)
  Extreme difficulty 177 (23%)
  Unable to perform activity 35 (4%)
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1

Percentages do not always add to 100% due to rounding.

2

Based on cut-off score in Lallukka et al. (2011).

3.3. Cannabis-Related Sleep Variables

Results in Table 2 indicated that, in this population of medical cannabis patients with chronic pain, sleep problems are relatively common and appear to be closely related to pain. In Table 3, we present descriptive statistics for the cannabis-related sleep variables. Consistent with the close relationship between pain and sleep problems, results showed that 80% of participants reported using cannabis in the past 1 month to improve sleep and, among these participants, cannabis was rated as relatively helpful for improving sleep. Similarly, results indicate about 80% of participants used cannabis to help sleep or because of sleep problems; by contrast, the use of cannabis to help with “napping” was reported by about 50% of participants. These results also show that cannabis-induced drowsiness was reported by about 35% of participants (cf. Whiting et al., 2015), but cannabis-induced insomnia was rare (~2%). By contrast, results in Table 3 indicate that sleep-related cannabis withdrawal symptoms were relatively common, with over 65% of participants reporting some form of sleep problem during the previous 2 weeks as a result of not using cannabis.

Table 3.

Cannabis-Related Sleep Variables at Baseline1

N (%) or Mean (SD)
1. Past 1 Month Use of Cannabis Use to Improve Sleep
  Yes 627 (80%)
  No 157 (20%)
2. Past 1 Month Helpfulness of Cannabis Use to Improve Sleep 8.4 (1.8)
3. Past 6 Months Frequency of Cannabis Use to Help You Sleep
  Never/Almost never 91 (12%)
  Rarely 48 (7%)
  Sometimes 117 (16%)
  Often 161 (22%)
  Always/Almost always 316 (43%)
4. Past 6 Months Frequency of Cannabis Use because You Are Having Problems Sleeping
  Never/Almost never 135 (19%)
  Rarely 65 (9%)
  Sometimes 108 (15%)
  Often 156 (21%)
  Always/Almost always 262 (36%)
5. Past 6 Months Frequency of Cannabis Use because Napping Easier/More Enjoyable
  Never/Almost never 357 (49%)
  Rarely 72 (10%)
  Sometimes 85 (12%)
  Often 81 (11%)
  Always/Almost always 129 (18%)
6. Experienced Insomnia from Marijuana or Prescription Pain Pills/Past 6 Months?
  Yes 15 (2%)
  No 767 (98%)
7. Experienced Drowsiness from Marijuana or Prescription Pain Pills/Past 6 Months?
  Yes 277 (35%)
  No 505 (65%)
8. Experienced Sleep Difficulty When Reduced or Stopped Cannabis/Past 6 Months?
  None 275 (36%)
  Mild 124 (16%)
  Moderate 179 (23%)
  Severe 197 (25%)
9. Experienced Strange Dreams When Reduced or Stopped Cannabis/Past 6 Months
  None 630 (82%)
  Mild 78 (10%)
  Moderate 40 (5%)
  Severe 20 (3%)
10. Trouble Falling/Staying Asleep, or Sleeping Too Much When Not Using Cannabis/2 Weeks
  Not at all 248 (32%)
  Several days 201 (26%)
  Over half the days 138 (18%)
  Nearly every day 180 (24%)
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1

Percentages do not always add to 100% due to rounding.

3.4. Correlates of Past 1-Month Sleep Disturbance

Table 4 includes the results from a series of bivariate and multiple logistic regression analyses of demographic and cannabis use correlates of past 1-month sleep disturbance. Results in Table 4 indicated that statistically significant demographic correlates of past 1-month sleep disturbance at the bivariate level included a.) older age, b.) being female, c.) being white, d.) being divorced/separated/ widowed, and e.) being retired/unemployed or on disability (relative to being employed). Statistically significant pain and cannabis use correlates of past 1-month sleep disturbance at the bivariate level included a) severity of usual pain during the past 1-month, b) not having a medical cannabis card, c) using cannabis medically on a “seldom” basis (relative to no use), and d) greater frequency of using cannabis to help sleep. When all variables were tested simultaneously in the same model, statistically significant correlates of past 1-month sleep disturbance included a) being female, b) being white, c) being on disability (relative to being employed), d) not having a medical cannabis card, and e) greater frequency of using cannabis to help sleep.

Table 4.

Demographic, Pain, and Cannabis Use Correlates of Past 1-Month Sleep Disturbance

Past 1 Month
Sleep Disturbance1
No Yes OR (95% CI) AOR (95% CI)
1. Age 44.5 46.7 1.01*(1.0 – 1.02) 1.0 (0.9 – 1.03)
2. Gender
  Female 34% 66% 1.7* (1.3 – 2.3) 1.7* (1.2 – 2.4)
  Male 47% 53% — —
3. Race/Ethnicity
  White 39% 61% 1.8* (1.2 – 2.7) 2.7* (1.6 – 4.6)
  Non-White 53% 47% — —
4. Education
  Less than HS/HS grad 39% 61% 1.1 (0.8 – 1.5) na
  Some college/College grad 42% 58% — na
5. Current Marital Status
  Married/Relationship 42% 59% 1.3 (0.9 – 1.8) 1.0 (0.6 – 1.5)
  Divorced/Separated/Widowed 31% 69% 2.1* (1.3 – 3.2) 1.5 (0.9 – 2.5)
  Never married 48% 52% — —
6. Employment Status
  Work full-time or part-time 49% 51% — —
  Disability 33% 67% 1.9* (1.4 – 2.7) 1.7* (1.1 – 2.6)
  Retired/Unemployed/Other 38% 62% 1.5* (1.1 – 2.2) 1.1 (0.7 – 1.8)
7. Usual Pain Past 1 Month 7.0 7.2 1.1* (1.02 – 1.2) 1.1 (0.99 – 1.3)
8. Currently Have a MMJ Card
  Yes 45% 55% — —
  No 34% 66% 1.6* (1.2 – 2.1) 1.7* (1.2 – 2.6)
9. Past 6 Months Freq of Marijuana Use/Medical Reasons
  No past 6-months medical use 34% 66% — —
  Very seldom 9% 91% 5.3*(1.4 – 19.2) 6.8 (0.9 – 41.6)
  Less than weekly 55% 45% 0.4 (0.2 – 1.1) 0.4 (0.1 – 1.7)
  1–2 days a week 52% 48% 0.5* (0.2 – 0.9) 0.5 (0.1 – 1.5)
  3–7 days a week 45% 55% 0.6 (0.4 – 1.1) 0.6 (0.2 – 1.8)
  Several times a day 38% 62% 0.8 (0.5 – 1.4) 0.6 (0.2 – 2.0)
10. Past 6 Months Freq of Marijuana Use/To Help Sleep
  Never/Almost never 60% 40% — —
  Rarely 48% 52% 1.6 (0.8 – 3.3) 1.7 (0.8 – 3.8)
  Sometimes 45% 55% 1.8* (1.1 – 3.2) 2.3* (1.2 – 4.3)
  Often 39% 61% 2.3* (1.4 – 4.0) 2.9* (1.6 – 5.3)
  Always/Almost always 35% 65% 2.8* (1.7 – 4.5) 3.5* (2.0 – 6.1)
11. Past 1 Month Avg. Quantity of Cannabis Use
  None 33% 67% —
  Less than 1/8 of an oz. 38% 62% 0.8 (0.4 – 1.4) na
  1/8 to slightly less than ¼ of an oz 44% 56% 0.6 (0.3 – 1.1) na
  ¼ to slightly less than ½ of an oz 40% 60% 0.7 (0.4 – 1.3) na
  ½ to slightly less than 1 oz 42% 68% 0.7 (0.3 – 1.3) na
  One or more ounces 39% 61% 0.8 (0.4 – 1.4) na
12. Past 1 Month Number of Hrs Felt High or Stoned on Avg. Day 2.8 2.7 0.9 (0.8 – 1.1) na
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1

Percentages do not always add to 100% due to rounding.

OR = odds ratio. AOR = adjusted odds ratio.

*

p < .05.

4. Discussion

The purpose of this study was to examine the nature, prevalence, and correlates of sleep-related problems in a sample of adults who report medical cannabis use for chronic pain. Results support several conclusions. First, sleep problems were common in this sample, and more than half (59%) of participants were classified as having a significant sleep disturbance. By comparison, the prevalence of clinically significant insomnia in the US general population is about 20% (Roth et al., 2011). Although subsequent analyses focused on a binary sleep disturbance variable, results showed that “waking up several times a night” was the most frequently endorsed sleep problem. Similarly, previous work found that “difficulty maintaining sleep” was among the most common symptoms of insomnia, and may have the largest impact on perceived health at the population level (Walsh et al., 2011). Pain was a prominent feature of sleep problems, and a substantial proportion of participants (approximately 30%) reported sleep problems occurring every night or multiple times per night. These findings are consistent with a large literature indicating close connections between sleep disturbances and chronic pain (Ferguson and Ware, 2015), and also suggest that subgroups of medical cannabis patients might be identifiable based on sleep problems and pain severity (e.g., Palagini et al., 2016).

The majority of participants (63%) reported that they “often” or “almost always/always” used cannabis to help sleep during the past 6 months, and cannabis was rated as helpful for improving sleep. Despite this frequent use, side effects of cannabis use were rarely reported. Results are similar to those reported by Bonn-Miller et al. (2014a), who found that, while insomnia was a common reason for seeking medical cannabis, using cannabis for sleep/rest was not associated with cannabis use problems. Of greater concern is that sleep-related cannabis withdrawal symptoms were relatively common. These results are similar to those from other studies of nonmedical cannabis users showing negative effects of cannabis withdrawal on PSG measures of sleep architecture (Bolla et al., 2008; Vandrey et al., 2011). Although the long-term health implications of cannabis withdrawal symptoms are unknown (Gates et al., 2015), our results suggest the need for further research to determine clinical relevance in medical cannabis patients.

Statistically significant correlates of past 1-month sleep disturbance included being female, being Caucasian, being on disability (relative to being employed), not having a previous medical cannabis card, and greater frequency of using cannabis to help sleep. Frequency of cannabis use for medical reasons, quantity of cannabis use, and cannabis intoxication were not associated with past 1-month sleep disturbance. These findings are generally consistent with research indicating that women appear to report more sleep problems than men (Krishnan and Collop, 2006), although previous work on race/ethnic differences in sleep problems has yielded mixed results (Adenekan et al., 2013). To our knowledge, this study is the first to report an association between disability status and sleep disturbance in medical cannabis patients with chronic pain. Compton et al. (2017) found that those who reported being “disabled for work” had higher odds of medical cannabis use compared to those who reported that they were working full-time, suggesting that sleep problems might be important to consider regarding the association between cannabis use and functional status. Although our cross-sectional design precludes inferences about temporal ordering of associations, other evidence showed that sleep problems predicted onset of disability (Friedman, 2016; Park et al., 2014).

Of particular interest is our finding that frequency of cannabis use to help sleep was associated with higher odds of sleep problems – even when other covariates were statistically controlled – whereas overall frequency and quantity of cannabis use and cannabis intoxication were not. Indeed, overall frequency of cannabis use for medical reasons and cannabis use to help sleep showed a statistically significant but weak positive relationship, r = .23. The magnitude of this correlation supports the discriminant validity of our measure of cannabis use to help sleep. In addition, the strong increase in the odds of sleep disturbance as a function of sleep-related cannabis use suggests several possible explanations.

One possible explanation for the findings is that more frequent sleep-related use of cannabis ultimately worsens sleep problems. This explanation is consistent with previous evidence for greater insomnia severity and lower sleep quality among daily cannabis users (Conroy et al., 2016), and with studies showing effects of cannabis on reductions in slow-wave and REM sleep (Conroy and Arnedt, 2014). It also seems plausible that those experiencing more severe sleep problems would be most likely to engage in sleep-related cannabis use. Another intriguing possibility is that sleep-related cannabis use is effective in the short-term but ineffective over the long term for reducing sleep disturbance (Angarita et al., 2016), and the results are indicative of more frequent sleep-related cannabis use aimed at reducing sleep problems that may have become intractable. This pattern of results could reflect a problematic cycle of cannabis use to reduce sleep problems, followed by exacerbation of sleep problems (perhaps due to cannabis cessation) and subsequent increases in use (Angarita et al., 2016; Babson et al., 2017). Importantly, because of the potential cyclical nature of sleep problems, increased cannabis use for sleep and greater frequency of sleep-related cannabis withdrawal symptoms, it is essential to examine longitudinal data to better understand how cannabis use and sleep interrelate over time.

We acknowledge several limitations to this study. First, the current research is based on cross-sectional data, making it impossible to discern the temporal direction of associations. Second, several of the measures we used were developed for this study and their psychometric properties have not been established. Third, we relied on self-report measures of sleep disturbance, and did not collect data on history of sleep problems prior to the pain condition or on diagnosis of physiological sleep disorder. Thus, our findings will require replication with laboratory assessments of sleep quality. Relatedly, although the items on the SPQ partially overlap with DSM-5 criteria for Insomnia Disorder (APA 2013), our study was not designed to detect clinical diagnoses. Further, our study is based on a sample of adult medical cannabis users from clinics in one Midwestern state, and given the considerable variability in state laws related to medical cannabis, the results may not generalize to other locations. Fourth, in those participants who were seeking a recertification card, we did not obtain information on what strain of medical cannabis they had been using. A previous study (Belendiuk et al., 2015) showed that medical cannabis users with insomnia used strains of cannabis with significantly higher concentrations of CBD, which may have affected interpretation of our findings. Finally, recent work showed some differences between medical and recreational cannabis users (Lin et al., 2016; Pacula et al., 2016), but the present study was limited to medical cannabis patients with chronic pain who reported that they were seeking cannabis for medical reasons.

Some preliminary data from smaller and short-term randomized trials indicated that cannabis use is associated with reductions in pain-related sleep disturbance (Rog et al., 2005). To date, however, clinical trials examining medical cannabis use and sleep have been characterized by small sample sizes (Whiting et al., 2015), making it difficult to draw definitive conclusions. In addition, recent reviews highlighted the need for research on long-term effects of medical cannabis for a number of conditions (D’Souza and Ranganathan, 2015), including sleep problems (Ferguson and Ware, 2015). Further research on sleep problems in medical cannabis patients using prospective longitudinal designs with larger sample sizes will clarify the strength, direction, and temporal order of these associations and their public health significance.

Highlights.

  • More than half of medical cannabis patients met criteria for sleep disturbance.

  • Most participants reported that sleep problems were due to their current pain.

  • 80% of participants used cannabis in the past 6 months to improve sleep.

  • Sleep-related cannabis withdrawal symptoms were relatively common (65%).

  • Disability status and using cannabis to help sleep were related to sleep problems.

Acknowledgments

We gratefully acknowledge Kierstdea Petzold for her assistance with data collection and management.

Role of Funding Source

This research was supported by grant R01 DA033397 from the National Institute on Drug Abuse (NIDA), National Institutes of Health. NIDA had no role in the study design; in the collection, analysis or interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Author Disclosures

Contributors

Dr. Ilgen (study principal investigator) conceptualized and designed the study. Drs. Cranford, Arnedt, Conroy, Bohnert, Blow, and Ilgen drafted the manuscript. Ms. Bourque was responsible for data collection and review of study methods. Dr. Cranford was responsible for data analysis, and all authors contributed to and have approved the final manuscript.

Conflict of Interest

No conflict declared.

References

  1. Adenekan B, Pandey A, McKenzie S, Zizi F, Casimir GJ, Jean-Louis G. Sleep in America: Role of racial/ethnic differences. Sleep Med. Rev. 2013;17:255–262. doi: 10.1016/j.smrv.2012.07.002. doi: http://dx.doi.org/10.1016/j.smrv.2012.07.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Agresti A. Categorical Data Analysis. third. John Wiley and Sons, Inc.; Hoboken, NJ: 2013. [Google Scholar]
  3. American Psychiatirc Association. Diagnostic and statistical manual of mental disorders (DSM- 5) American Psychiatric Association; Arlington, VA: 2013. [Google Scholar]
  4. Angarita GA, Emadi N, Hodges S, Morgan PT. Sleep abnormalities associated with alcohol, cannabis, cocaine, and opiate use: A comprehensive review. Addict. Sci. Clin. Pract. 2016;11:9. doi: 10.1186/s13722-016-0056-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Arnedt JT, Conroy DA, Brower KJ. Treatment options for sleep disturbances during alcohol recovery. J. Addict. Dis. 2007;26:41–54. doi: 10.1300/J069v26n04_06. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Babson KA, Bonn-Miller MO. Sleep disturbances: Implications for cannabis use, cannabis use cessation, and cannabis use treatment. Curr. Addict. Rep. 2014;1:109–114. doi: 10.1007/s40429-014-0016-9. [DOI] [Google Scholar]
  7. Babson KA, Sottile J, Morabito D. Cannabis, cannabinoids, and sleep: A review of the literature. Curr. Psychiatry Rep. 2017;19:23. doi: 10.1007/s11920-017-0775-9. [DOI] [PubMed] [Google Scholar]
  8. Belendiuk K, Babson K, Vandrey R, Bonn-Miller M. Cannabis species and cannabinoid concentration preference among sleep-disturbed medicinal cannabis users. Addict. Behav. 2015;50:178–181. doi: 10.1016/j.addbeh.2015.06.032. doi: http://dx.doi.org/10.1016/j.addbeh.2015.06.032. [DOI] [PubMed] [Google Scholar]
  9. Benbadis SR, Sanchez-Ramos J, Bozorg A, Giarratano M, Kalidas K, Katzin L, Robertson D, Vu T, Smith A, Zesiewicz T. Medical marijuana in neurology. Exp. Rev. Neurother. 2014;14:1453–1465. doi: 10.1586/14737175.2014.985209. [DOI] [PubMed] [Google Scholar]
  10. Bohnert KM, Bonar EE, Arnedt JT, Conroy DA, Walton MA, Ilgen MA. Properties and utility of the comprehensive marijuana motives questionnaire among medical cannabis patients. Under Review. doi: 10.1016/j.addbeh.2017.08.001. in press. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Bolla KI, Lesage SR, Gamaldo CE, Neubauer DN, Funderburk FR, Cadet JL, David PM, Verdejo-Garcia A, Benbrook AR. Sleep disturbance in heavy marijuana users. Sleep. 2008;31:901–8. doi: 10.1093/sleep/31.6.901. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Bolla KI, Lesage S, Gamaldo C. Polysomnogram changes in marijuana users who report sleep disturbances during prior abstinence. Sleep Med. 2010;11:882–889. doi: 10.1016/j.sleep.2010.02.013. doi: http://dx.doi.org/10.1016/j.sleep.2010.02.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Bonn-Miller MO, Babson KA, Vandrey R. Using cannabis to help you sleep: Heightened frequency of medical cannabis use among those with PTSD. Drug Alcohol Depend. 2014a;136:162–165. doi: 10.1016/j.drugalcdep.2013.12.008. doi: http://dx.doi.org/10.1016/j.drugalcdep.2013.12.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Bonn-Miller MO, Boden MT, Bucossi MM, Babson KA. Self-reported cannabis use characteristics, patterns and helpfulness among medical cannabis users. Am. J. Drug Alcohol Abuse. 2014b;40:23–30. doi: 10.3109/00952990.2013.821477. [DOI] [PubMed] [Google Scholar]
  15. Budney AJ, Novy PL, Hughes JR. Marijuana withdrawal among adults seeking treatment for marijuana dependence. Addiction. 1999;94:1311–1322. doi: 10.1046/j.1360-0443.1999.94913114.x. [DOI] [PubMed] [Google Scholar]
  16. Compton WM, Han B, Hughes A, Jones CM, Blanco C. Use of marijuana for medical purposes among adults in the United States. JAMA. 2017;317:209–211. doi: 10.1001/jama.2016.18900. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Conroy DA, Arnedt JT. Sleep and substance use disorders: An update. Curr. Psychiatry Rep. 2014;16:487. doi: 10.1007/s11920-014-0487-3. [DOI] [PubMed] [Google Scholar]
  18. Conroy DA, Kurth ME, Strong DR, Brower KJ, Stein MD. Marijuana use patterns and sleep among community-based young adults. J. Addict. Dis. 2016;35:135–143. doi: 10.1080/10550887.2015.1132986. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Cranford JA, Bohnert KM, Perron BE, Bourque C, Ilgen M. Prevalence and correlates of “vaping” as a route of cannabis administration in medical cannabis patients. Drug Alcohol Depend. 2016;169:41–47. doi: 10.1016/j.drugalcdep.2016.10.008. doi: http://dx.doi.org/10.1016/j.drugalcdep.2016.10.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. D'Souza DC, Ranganathan M. Medical marijuana: Is the cart before the horse? JAMA. 2015;313:2431–2432. doi: 10.1001/jama.2015.6407. [DOI] [PubMed] [Google Scholar]
  21. Farrar JT, Young JP, Jr, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94:149–158. doi: 10.1016/S0304-3959(01)00349-9. doi: http://dx.doi.org/10.1016/S0304-3959(01)00349-9. [DOI] [PubMed] [Google Scholar]
  22. Ferguson G, Ware M. Review article: Sleep, pain and cannabis. J. Sleep Disord. Ther. 2015;4:1–5. doi: http://dx.doi.org/10.4172/2167-0277.1000191. [Google Scholar]
  23. Friedman EM. Self-reported sleep problems prospectively increase risk of disability: Findings from the Survey of Midlife Development in the United States. J. Am. Geriatr. Soc. 2016;64:2235–2241. doi: 10.1111/jgs.14347. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Gaedeke K. Health Licensing Division, Bureau of Professional Licensing, Michigan Department of Licensing and Regulatory Affairs. Lansing, MI: 2016. Medical Marihuana Act statistical report for fiscal Year 2015 (pursuant to MCL 333.26426 (i) (1), (2), (3), (4) and (5)) [Google Scholar]
  25. Gates P, Albertella L, Copeland J. Cannabis withdrawal and sleep: A systematic review of human studies. Subst. Abuse. 2016;37:255–269. doi: 10.1080/08897077.2015.1023484. [DOI] [PubMed] [Google Scholar]
  26. Hendler N, Mollett A, Talo S, Levin S. A comparison between the Minnesota Multiphasic Personality Inventory and the Mensana Clinic Back Pain Test for validating the complaint of chronic back pain. J. Occup. Environ. Med. 1988;30:98–102. [PubMed] [Google Scholar]
  27. Hendler N, Viernstein M, Gucer P, Long D. A preoperative screening test for chronic back pain patients. Psychosomatics. 1979;20:801–808. doi: 10.1016/S0033-3182(79)73719-4. doi: http://dx.doi.org/10.1016/S0033-3182(79)73719-4. [DOI] [PubMed] [Google Scholar]
  28. Jenkins CD, Stanton BA, Niemcryk SJ, Rose RM. A scale for the estimation of sleep problems in clinical research. J. Clin. Epidemiol. 1988;41:313–321. doi: 10.1016/0895-4356(88)90138-2. doi: http://dx.doi.org/10.1016/0895-4356(88)90138-2. [DOI] [PubMed] [Google Scholar]
  29. Krishnan V, Collop NA. Gender differences in sleep disorders. Curr. Opin. Pulm. Med. 2006;12:383–389. doi: 10.1097/01.mcp.0000245705.69440.6a. [DOI] [PubMed] [Google Scholar]
  30. Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatr. Ann. 2002;32:509–515. doi: 10.3928/0048-5713-20020901-06. [DOI] [Google Scholar]
  31. Lallukka T, Haaramo P, Lahelma E, Rahkonen O. Sleep problems and disability retirement: A register-based follow-up study. Am. J. Epidemiol. 2011;173:871–881. doi: 10.1093/aje/kwq462. [DOI] [PubMed] [Google Scholar]
  32. Lee CM, Neighbors C, Hendershot CS, Grossbard JR. Development and preliminary validation of a Comprehensive Marijuana Motives Questionnaire. J. Stud. Alcohol Drugs. 2009;70:279–287. doi: 10.15288/jsad.2009.70.279. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Lin LA, Ilgen MA, Jannausch M, Bohnert KM. Comparing adults who use cannabis medically with those who use recreationally: Results from a national sample. Addict. Behav. 2016;61:99–103. doi: 10.1016/j.addbeh.2016.05.015. doi: http://dx.doi.org/10.1016/j.addbeh.2016.05.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. National Academies of Sciences, Engineering, and Medicine. The Health Effects Of Cannabis And Cannabinoids: The Current State Of Evidence And Recommendations For Research. The National Academies Press; Washington, DC: 2017. [DOI] [PubMed] [Google Scholar]
  35. National Conference of State Legislatures. State medical marijuana laws. 2017 Retrieved from http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx 17 July 2017.
  36. Pacula RL, Jacobson M, Maksabedian EJ. In the weeds: A baseline view of cannabis use among legalizing states and their neighbours. Addiction. 2016;111:973–980. doi: 10.1111/add.13282. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Palagini L, Faraguna U, Mauri M, Gronchi A, Morin CM, Riemann D. Association between stress-related sleep reactivity and cognitive processes in insomnia disorder and insomnia subgroups: Preliminary results. Sleep Med. 2016;19:101–107. doi: 10.1016/j.sleep.2015.10.020. doi: http://dx.doi.org/10.1016/j.sleep.2015.10.020. [DOI] [PubMed] [Google Scholar]
  38. Park M, Buchman AS, Lim ASP, Leurgans SE, Bennett DA. Sleep complaints and incident disability in a community-based cohort study of older persons. Am. J. Geriatr. Psychiatry. 2014;22:718–726. doi: 10.1016/j.jagp.2012.12.023. doi: http://dx.doi.org/10.1016/j.jagp.2012.12.023. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Rog DJ, Nurmikko TJ, Friede T, Young CA. Randomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosis. Neurology. 2005;65:812–819. doi: 10.1212/01.wnl.0000176753.45410.8b. [DOI] [PubMed] [Google Scholar]
  40. Roth T, Coulouvrat C, Hajak G, Lakoma MD, Sampson NA, Shahly V, Shillington AC, Stephenson JJ, Walsh JK, Kessler RC. Prevalence and perceived health associated with insomnia based on DSM-IV-TR; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision; and Research Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition Criteria: Results from the America Insomnia Survey. Biol. Psychiatry. 2011;69:592–600. doi: 10.1016/j.biopsych.2010.10.023. doi: http://dx.doi.org/10.1016/j.biopsych.2010.10.023. [DOI] [PubMed] [Google Scholar]
  41. Stratford PW, Binkley JM, Riddle DL. Development and initial validation of the Back Pain Functional Scale. Spine. 2000;25:2095–2102. doi: 10.1097/00007632-200008150-00015. [DOI] [PubMed] [Google Scholar]
  42. Vandrey R, Smith MT, McCann UD, Budney AJ, Curran EM. Sleep disturbance and the effects of extended-release zolpidem during cannabis withdrawal. Drug Alcohol Depend. 2011;117:38–44. doi: 10.1016/j.drugalcdep.2011.01.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Volkow ND, Hampson AJ, Baler RD. Don’t worry, be happy: Endocannabinoids and cannabis at the intersection of stress and reward. Annu. Rev. Pharmacol. Toxicol. 2017;57:285–308. doi: 10.1146/annurev-pharmtox-010716-104615. [DOI] [PubMed] [Google Scholar]
  44. Walsh JK, Coulouvrat C, Hajak G, Lakoma MD, Petukhova M, Roth T, Sampson NA, Shahly V, Shillington A, Stephenson JJ, Kessler RC, Stephenson JJ. Nighttime insomnia symptoms and perceived health in the America Insomnia Survey (AIS) Sleep. 2011;34:997–1011. doi: 10.5665/SLEEP.1150. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA. 2015;313:2456–2473. doi: 10.1001/jama.2015.6358. [DOI] [PubMed] [Google Scholar]
  46. Wilkinson ST, Yarnell S, Radhakrishnan R, Ball SA, D’Souza DC. Marijuana legalization: Impact on physicians and public health. Annu. Rev. Med. 2016;67:453–466. doi: 10.1146/annurev-med-050214-013454. [DOI] [PMC free article] [PubMed] [Google Scholar]

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