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. Author manuscript; available in PMC: 2022 Feb 1.
Published in final edited form as: Sleep Health. 2020 Aug 2;7(1):113–117. doi: 10.1016/j.sleh.2020.06.008

Marijuana versus Evidence-Based Treatments for Sleep and Relaxation: A Cross-Sectional Study of Use and Dose Modification following Involuntary Job Loss

Iva Skobic a,*, Gabriella R Apolinar a, Stuart F Quan a,b, Patricia L Haynes a
PMCID: PMC7855254  NIHMSID: NIHMS1618850  PMID: 32758411

Abstract

Objectives

Sleep disruption and relaxation are commonly cited reasons for marijuana use. Job loss is a significant stressor associated with high risk for sleep disruption. Little is known about marijuana use in relation to other intervention choices for sleep/relaxation in individuals who have experienced recent, involuntary job loss.

Methods

This study compared self-reported use of marijuana to evidence-based treatments (EBT) for sleep/relaxation using data from the ongoing Assessing Daily Activity Patterns through Occupational Transitions (ADAPT) study. Participants were 1639 completers of the ADAPT phone screen interview. EBT was defined as Cognitive Behavioral Therapy for Insomnia (CBT-I), non-benzodiazepine sedatives/hypnotics, and benzodiazepines.

Results

Marijuana was the most common treatment for sleep/relaxation. Two-sample tests of proportions revealed that prevalence of use of marijuana was comparable to the entire class of EBTs (~ 4.5%). Only 2 (0.1%) participants reported receiving CBT-I, the first-line treatment for insomnia disorder, as per the American College of Physicians Clinical Practice Guidelines. Rates of dose increase following job-loss were comparable between users of marijuana and EBTs (Z=.55, p=.58). Multiple logistic regression models demonstrated that male sex (OR=.28, 95% CI=.14-.57) and substance abuse (OR=7.68, 95% CI=2.89–20.43) were significantly associated with increased likelihood of marijuana use.

Conclusions

Individuals who have recently experienced involuntary job loss may be more likely to use marijuana than any one EBT for sleep/relaxation and as likely to increase their treatment dose. Dissemination of evidence-based sleep health interventions is needed in unemployed populations to prevent habitual patterns resulting in the long-term use of marijuana for sleep/relaxation.

Keywords: marijuana, evidence-based treatments, insomnia, cognitive behavior therapy, sedatives, benzodiazepines

Introduction

Nearly a third of the United States population, an estimated 50–70 million individuals, is hindered by chronic disorders of sleep and wakefulness, and this number is increasing [1]. Medical visits due to sleep disturbances increased 29% from 1999 to 2010, accounting for over eight million visits in 2010 [2]. These visits resulted in an approximately 300% increase in the number of prescriptions written for sleep medications, with 20.8 million prescriptions written in 2010 [2]. Hyperarousal is a common cause of insomnia and other sleep complaints [3, 4]. Treatments and strategies that promote relaxation and address hyperarousal are often recommended for those suffering from sleep complaints [3, 5]. Efficacious, evidence-based treatments (EBT) for sleep and relaxation problems are widely available and include psychological treatments such as Cognitive Behavioral Therapy for Insomnia (CBT-I) [6] and pharmacological interventions [7]. Yet, many individuals experiencing sleep and relaxation problems turn to marijuana for symptom relief [8–11] even though marijuana has varying levels of legality across the United States [12].

Sleep improvement and relaxation are two of the most commonly cited reasons for marijuana use in the United States, with up to 80% of research participants citing sleep as a common reason for their marijuana use [9, 11, 13–16]. Some short-term sleep benefits have been reported among marijuana users, including decreased sleep latency [9, 17], but long-term use often leads to habituation and a worsening of symptoms [9, 11, 17]. In fact, heavy use of marijuana over time is associated with shorter total sleep, less slow wave sleep, worse sleep efficiency, decreased REM latency, increased sleep latency, and frequent waking after sleep, especially immediately following discontinuation [17–19]. Yet, once individuals begin using marijuana to aid sleep and relaxation, they generally prefer it over other treatments and report fewer side effects and better symptom management [14, 16]. When abstaining from marijuana, sleep-related disturbances are the most common withdrawal symptom [9, 15, 17]. In addition to marijuana consumption, there is increasing interest in use of cannabinoids for sleep and relaxation. Cannabidiol (CBD), a non-intoxicating component of cannabis with a low addiction profile, is increasingly relevant due to its potential therapeutic effects [9]. Medium and high doses of CBD have been found to be sedating [20, 21], and one study found that 160 mg/day of CBD can increase total sleep time and decrease the number of awakenings during the night [22]. On the other hand, tetrahydrocannabinol (THC), the main psychoactive component of cannabis, may decrease sleep latency [20] but has also been shown to interfere with the circadian sleep-wake cycle [9] and reduce somnolence with chronic, high-dose use [23]. A high dose of THC at night (15mg) may also result in memory impairment, increased sleepiness, and changes in mood the day following administration [20].

Access to and use of marijuana and cannabinoids have increased rapidly since the early 2000’s due to increased legality and changing opinions regarding potential health benefits of marijuana use [8, 24, 25]. Whites, males, and younger or middle-aged adults are more likely to use marijuana than their non-White, female, and older counterparts [13–16], and marijuana use often co-occurs with other substance use, legal and illegal [16, 26, 27].

Individuals who use marijuana are at higher risk of job loss and continued unemployment [28, 29]. Research has also demonstrated an association between stressful life events, such as job loss, and symptoms of anxiety and insomnia, including difficulty falling asleep at bedtime and staying asleep throughout the night [30, 31]. Therefore, marijuana use for sleep and relaxation may contribute to a vicious cycle of unemployment, substance abuse, and sleep disruption. More research into marijuana versus EBT use for sleep and relaxation is needed to better understand patterns of marijuana use and inform public health interventions.

Our primary objective for the present study was to investigate the prevalence of marijuana use to sleep or relax in a sample of individuals who had recently experienced involuntary job loss. We compared the prevalence of use of marijuana to prevalence of use of EBTs in this sample, and we hypothesized that the prevalence of marijuana use to sleep or relax would be equal to or higher to use of EBTs. We also hypothesized that, after job loss, participants would be more likely to report an increase (vs. maintain or decrease) in their use of marijuana as compared to their EBT use.

Finally, we examined potential associations between marijuana use and gender, age, substance abuse problems, and length of employment at previous job. Based on the literature, we hypothesized that male gender, identification as White and non-Hispanic, younger age, self-acknowledged drug/alcohol abuse problems, and shorter period of employment at previous job would be associated with greater odds of marijuana use to sleep or relax following job loss.

Participants and Methods

Study Sample

The Assessing Daily Activity Patterns through Occupational Transitions (ADAPT) study is an 18-month longitudinal observational study examining the linkages between sleep, social rhythms, and obesity among eligible individuals who have involuntarily lost their jobs in the past three months [32]. The study protocol and methods have been described in detail elsewhere [32]. Briefly, purposive sampling was employed to recruit all individuals in the Tucson area applying for unemployment insurance through the Arizona Department of Economic Security from October 26, 2015 to December 3, 2018. All participants who responded to a flyer in their intake packet were interviewed by phone to determine eligibility and interest. The current analyses used data gathered from that initial phone interview assessing eligibility for the cohort study.

Phone Interview

Study staff administered a two-tiered phone screen instrument in an approximately 10-minute, structured oral interview format. Demographic information was collected, including age, sex, ethnicity, and race, as well as questions related to their recent job loss, recent drug use, and medical and mental health history.

The analyses used data from a subset of individuals who were required to have (1) experienced involuntary job loss in the last three months, (2) worked at their previous place of employment for more than six months, and (3) completed the full screening interview. Involuntary job loss was defined as having lost a job either through termination or lay-off, not through voluntarily having quit or retired.

To determine recent use of drugs or medications to sleep or relax, participants were asked “Have you recently taken any drugs or medications to help you sleep or relax? Consider the last 6 weeks.” Specific drug or medication use was determined with the question “Which medications?” Participants who reported having used marijuana to sleep or relax in the past six weeks were considered positive for marijuana use (MJ+). Participants who reported having used a non-benzodiazepine sedative/hypnotic sleep aid or a benzodiazepine were considered EBT users for the primary analysis.

Participation in CBT-I was measured with the yes/no question “Have you participated in Cognitive Behavioral Therapy for Insomnia (in the last 6 weeks)?” Marijuana and EBT were coded as binary (yes/no) variables; individuals could be coded ‘yes’ in both categories. Increase in drug or medication use following job loss was measured with the multiple choice question, “Since losing your job, has your Drug-X dose increased, decreased, or stayed the same?” This question was repeated for each drug or medication reported by the participant.

Statistical Analysis

All data were analyzed using the SAS University Edition statistical analysis program [33]. Descriptive statistics were computed to determine prevalence of marijuana and EBT use. A two-sample test of proportions was conducted to determine statistical difference in marijuana versus EBT use prevalence. A second two-sample test of proportions was conducted to determine the statistical difference in marijuana versus EBT dose increase following job loss. All reported p-values were 2-sided, with an α level of 0.05.

Multiple logistic regression models were used to examine the association between use of marijuana to sleep or relax and six potential correlates: sex, age, race, ethnicity, self-reported drug/alcohol abuse problem (binary, yes/no), and time employed at previous job (continuous, in months). These potential correlates were chosen a priori based on existing literature and the study hypotheses. Goodness of fit for logistic regression models was assessed using the concordance statistic (c-statistic) and the Hosmer and Lemeshow goodness of fit test.

Sensitivity Analysis

For our sensitivity analysis, we first re-computed our models including tricyclic antidepressants in our definition of EBT. Tricyclic antidepressants, such as trazodone, are one of the most commonly prescribed treatments for insomnia [34]. Although a 2017 review found that trazodone is effective in decreasing sleep latency and increasing sleep duration [35], tricyclic antidepressants are not currently approved by the U.S. Food and Drug Administration (FDA) for insomnia [35], and there is some question as to their efficacy as a treatment for hyperarousal, insomnia, and sleep disturbances in individuals not reporting major depression [34, 36, 37]. They were thus not included as EBTs in the primary analysis.

Next, we compared prevalence of use of marijuana to prevalence of use of each individual EBT category (CBT-I, non-benzodiazepine sedatives, benzodiazepines, and tricyclic antidepressants). Finally, we removed individuals who reported use of both marijuana and EBTs from analysis to assess differences with main findings.

Results

Demographics

A total of 1,639 individuals completed the entire phone screen. Of these 1,639, 473 participants (29%) reported having recently received CBT-I and/or taken any drugs or medications to sleep or relax. Eighty survey completers (4.9% of the sample) reported use of marijuana and 75 (4.6% of the sample) reported use of EBT. Five participants (0.2%) reported using both marijuana and an EBT; these individuals were included in both groups in the primary analysis and removed from the sample as part of the sensitivity analysis. Descriptive participant characteristics stratified by treatment group are reported in Table 1. Our dataset had missing sex, ethnicity, and race data (38–55%) due to the late addition of these variables into the phone screen.

Table 1.

Descriptive characteristics of phone screen participants for the Assessing Daily Activity Patterns through Occupational Transitions (ADAPT) study who completed the interview (N= 1639), stratified by treatment group (marijuana [MJ+] versus evidence-based treatments [EBT1]).

Characteristic MJ+ (N = 80) EBT 1 (N = 75) All Participants (N =1639)
Prevalence 4.9% 4.6%4
Age, Mean(SD) 40 (11) 46 (11) 42 (12)
Sex
Male 53 (69) 22 (30) 453 (44)
Female 24 (31) 51 (70) 571 (56)
Ethnicity
Non-Hispanic/Latino 26 (54) 26 (67) 526 (63)
Hispanic/Latino 22 (46) 13 (33) 308 (37)
Race
Non-White2 12 (30) 4 (11) 208 (28)
White 28 (70) 31 (89) 535 (72)
Substance Abuse3
Yes 12 (15) 5 (7) 81 (5)
No 68 (85) 70 (93) 1552 (95)
Time at previous job (in months), Mean(SD) 30 (35) 40 (45) 36 (50)
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*

All data is presented in N(%) unless otherwise specified.

1

EBTs for sleep/relaxation in this analysis included Cognitive Behavioral Therapy for Insomnia (CBT-I), Sedatives/Hypnotic sleep aids, and Benzodiazepines

2

Non-White included American Indian or Alaskan Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and More than One Race

3

Measured with the yes/no question “Do you or does anyone close to you think that you might have an alcohol or drug use problem?”

4

1.4% reported using sedatives/hypnotics, 3.2% benzodiazepines, and .12% CBT. Note: Ethnicity and race had < 50% missing data. Ethnicity and race data were available for 834 and 743 participants, respectively.

Participants in the MJ+ group were on average younger and were more likely to be male than EBT users, while EBT users were predominantly female and a larger percentage reported being White and non-Hispanic. A majority of both the MJ+ and EBT groups were White and non-Hispanic, which was representative of our sample. Participants in the MJ+ group were more likely than EBT users to report a substance abuse problem and reported on average shorter periods of time at their previous places of employment.

Marijuana vs. EBT use prevalence and dose increase

We found no significant difference in prevalence of use of marijuana (4.9%, n=80) and use of EBTs as a class of treatments (4.6%, n=75; z = .41, p =.68). Participants in the MJ+ group were slightly more likely to report a dose increase after job loss than users of EBTs, but this difference was not significant (z = .56, p = .58).

Correlates of marijuana use

Table 2 shows the results of our multiple logistic regression analyses for variables associated with use of marijuana for sleep and relaxation post-job loss. In both models, sex was found to be robustly associated with use of marijuana post-job loss, with women having significantly lower odds of reporting use of marijuana than men. A self-reported drug or alcohol problem was also associated with increased risk of use of marijuana for sleep and relaxation. The remaining variables of interest were not found to have a significant association with use of marijuana when controlling for other variables.

Table 2.

Summary of logistic regression analysis for variables associated with use of marijuana to sleep or relax post-job loss.

Variables of interest OR 95% CI
Model 1*
Sex1 .35 .21 – .57
Age .99 .97 – 1.01
Time at previous job2 1.00 .99 – 1.00
Substance abuse1 3.44 1.61 – 7.33
Model 2**
Sex1 .28 .14 – .57
Age1 < 25 reference reference
25–35 .92 .19 – .4.42
35–50 1.01 .21 – 4.76
>50 .89 .18 – 4.48
Ethnicity1 1.28 .63 – 2.60
Race1 .99 .48 – 2.04
Time at previous job2 .99 .98 – 1.00
Substance abuse1 7.68 2.89 – 20.43
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Note: sample sizes reflect exclusion of observations with missing age, sex, race, and ethnicity variables.

*

n = 1004, c-statistic = .68, p = .70 (Hosmer & Lemeshow)

**

n = 725 c-statistic = .76, p = .995 (Hosmer & Lemeshow)

1

Male sex, age < 25, non-Hispanic ethnicity, White race, and no reported drug or alcohol problem were used as the reference categories.

2

In months.

Sensitivity Analysis

The addition of tricyclic antidepressants to our definition of EBT led to a significantly lower prevalence of marijuana than EBT use in our sample (z = −3.05, p = .002). There was no statistical difference in the proportion of recently unemployed individuals reporting an increase in EBT versus marijuana use after addition of tricyclic antidepressants (z = .75, p = .45).

When the data were analyzed using EBT categories as separate variables (i.e., use of CBT-I, non-benzodiazepine sedative/hypnotic sleep aids, or benzodiazepines, respectively), marijuana was found to be the single most common treatment for sleep and relaxation. Only 2 (0.1%) participants received CBT-I, 23 (1.4%) used non-benzodiazepine sedatives/hypnotics, 52 (3.1%) used benzodiazepines, and 50 (3.05%) used tricyclic antidepressants. Significantly more participants reported use of marijuana for sleep or relaxation than use of CBT-I (z = 8.72, p < .00001), non-benzodiazepine sedatives (z = 5.71, p < .00001), benzodiazepines (z = 2.49, p = .01), or tricyclic antidepressants (z = 2.69, p = .007).

Removal of individuals who used both marijuana and EBTs (n = 5) from our sample did not significantly change the proportion of individuals who used each type of treatment (z = .42, p = .67), nor trends in marijuana increase following job-loss (z = .58, p =.56). Multiple logistic regression analysis using this reduced sample found that the same two variables (male sex and a self-reported substance abuse problem) were significantly associated with increased odds of use of marijuana (OR = 0.35, CI = .21 - .59 and OR = 2.86, CI = 1.26 – 6.50, respectively).

Discussion

Nearly a third of our sample of recently unemployed individuals reported using a treatment for sleep or relaxation. Of these, significantly more individuals reported using marijuana than any one category of EBT (i.e., CBT-I, non-benzodiazepine sedative/hypnotic sleep aids, benzodiazepines, respectively). However, rates of use of marijuana and EBTs in aggregate were comparable. Our sensitivity analysis revealed that significantly more participants used marijuana than tricyclic antidepressants (e.g., trazodone), a common (but non-EBT) treatment for sleep [36, 37]. The addition of tricyclic antidepressants into the definition of EBTs changed the ratio of MJ+ group to EBT participants so that significantly more participants reported use of EBTs than marijuana. In addition, more participants reported using tricyclic antidepressants than certain categories of EBTs, such as non-benzodiazepine sedatives/hypnotics and CBT-I. Our results demonstrate interest in and the need for additional research into tricyclic antidepressants for sleep and relaxation. Overall findings suggest that patients may require a wide range of options when it comes to sleep and relaxation treatments; adding affordable pharmacological options could increase rates of use of EBTs and lower the use of generally unregulated products, such as marijuana. The rate of use of marijuana for sleep and relaxation in our sample is troubling given the legal risks associated with use of marijuana in many parts of the United States [12] and around the world [38]. An additional concern is the risk of rapid habituation [39] and worsening of sleep symptoms among heavy users [40] and those who discontinue use of marijuana [9, 11, 18]. Educating patients who are heavy marijuana users about these risks may be beneficial.

Approximately one third of participants in the MJ+ group and one third of pharmacological EBT users in our sample reported increasing their sleep/relaxation treatment dose after job loss. Research has shown that stressful life events such as job loss may interfere with individuals’ length and quality of sleep [30]; worse sleep may lead individuals to seek an increase in sleep/relaxation medication dosage. While a temporary increase in EBT dosage for sleep and relaxation problems may be beneficial following job loss, recently unemployed individuals may lack medical insurance coverage or the funds necessary to engage in the medical system [41]. A lack of access to medical care may thus make marijuana an attractive option for sleep and relaxation problems following job loss.

Men in our sample were significantly more likely to fall into the MJ+ group than women, while women were significantly more likely than men to use EBTs. These findings are consistent with the existing literature on trends in both marijuana use [42] and clinical treatment seeking [43]. In general, women may be more likely to seek legal, evidence-based treatments and more readily engage in formal help-seeking behaviors than men [44]. Our data did not show a strong association between age, ethnicity, race, time at previous job and marijuana use.

Empirical evidence points to the detrimental effects of marijuana use on employment and income potential [29]. Use of marijuana may create a vicious cycle between stressful life events and poor sleep outcomes, with heavy users more likely to experience job loss, develop or experience a worsening in sleep problems, and subsequently increase their marijuana use [29]. Moreover, given marijuana’s inconsistent legality across the United States [12], its use in many states carries serious legal risks. More research is needed into the economic, medical, and personal factors influencing individuals’ decisions to use marijuana versus EBTs, as well as the long-term effects of marijuana for sleep/relaxation. Interventions are needed to address common misconceptions on the benefits of marijuana use for sleep/relaxation and the resulting overdependence on the drug to self-treat sleep symptoms.

There were several limitations to our study. Although there was little missing data in our outcome variables (<1% missing in marijuana/EBT use and dose change post-job loss), sex, race, and ethnicity had a large percentage of missing data since these data were not collected in the phone screen at the initiation of the study. Data were not available on length or severity of sleep symptoms. We were thus unable to speculate fully regarding the precipitating role of job loss on sleep symptoms, nor on the low rate of utilization of CBT-I, the gold standard for chronic insomnia (typically defined as lasting more than 3 months) [45]. Moreover, data were not available on frequency of marijuana or EBT use in our sample. It is possible that some participants used marijuana infrequently for sleep and relaxation and did not experience the severity or frequency of symptoms that would warrant an insomnia diagnosis.

In a related vein, data were also not available on whether participants used marijuana recreationally and thus may have continued or increased their marijuana use post-job loss regardless of sleep symptoms, or if they had sought-out marijuana only for the perceived medicinal effects of marijuana on sleep and hyperarousal post-job loss. This concern is somewhat mitigated by the question wording, which queried about marijuana use specifically for the purpose of facilitating sleep or relaxation. In addition, the question was administered during a portion of the interview which inquired about receipt of different types of medical treatments. Although wording and timing of the question may have increased the likelihood of solely recreational users (i.e., those who were not using marijuana specifically for sleep and relaxation difficulties) replying in the negative, data were not collected on overall marijuana use to ascertain any relevant differences between groups.

No data were collected on variables related to education and other markers of socio-economic status, which may have influenced participants’ knowledge and choices of sleep and relaxation treatments, as well as their access to EBTs. In some cases, wording of certain questions was also a limitation as it was impossible to assess whether participants were seeking treatment for sleep or relaxation. However, research has shown that sleep and relaxation are closely related constructs, and the same treatments are commonly used to achieve both relaxation and better sleep [46–50]. In fact, users of both marijuana and EBTs may use relaxation treatments in the evenings to help them fall asleep later at night. For example, relaxation treatments in the evenings are often used as part of CBT-I to decrease sleep latency later at night [46]. More research is needed on the differentiation between relaxation and sleep in terms of treatment-seeking.

Because of the cross-sectional nature of the data collection, establishment of temporality and causality between variables such as unemployment and marijuana use was impossible. Although all individuals in Tucson who applied for unemployment insurance were sampled, results may be generalizable only to people are interested in research participation specifically. Finally, the self-report nature of the questions may have introduced the potential for recall bias and desirability bias; individuals may have under-reported marijuana use since it is illegal in Arizona without a prescription.

Strengths of our study included a unique sample of individuals who had recently experienced involuntarily job loss. In addition, the sample was not limited solely to medical marijuana card holders. Most research to date has focused on samples of medical marijuana applicants and cardholders [13, 26, 27]. In addition, this research was innovative in its contribution to a budding field of research into marijuana use for sleep and relaxation, while advancing a new line of inquiry into increase of sleep and relaxation treatments following job loss.

Conclusions

Individuals who have experienced a stressful life event, such as job loss, may be more likely to use marijuana than any one EBT for sleep and relaxation. Sleep health interventions are needed to prevent habitual patterns resulting in the long-term use of marijuana for sleep and relaxation. This study supports the need for a widespread dissemination of secondary prevention programs for sleep and marijuana use, especially among individuals who have involuntarily lost their jobs.

Acknowledgments

The authors wish to acknowledge the contributions of Candace Mayer, Devan Gengler, April Yingst, Darlynn Rojo-Wissar, Mario Trejo, and Dr. Melanie Bell. The research was supported with resources and the use of facilities at The University of Arizona Clinical and Translational Sciences Research Center and The University of Arizona Collaboratory for Metabolic Disease Prevention and Treatment.

This work was supported by the National Heart, Lung, and Blood Institute (#1R01HL117995-01A1; PI: Haynes).

Footnotes

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