The Hemp Farming Act of 2018 removed hemp, which is defined as cannabis with less than 0.3% tetrahydrocannabinol (THC), from Schedule I controlled substances and made it an ordinary agricultural commodity.1 Since then, a plethora of new research and CBD products have come on the market in a very short period of time.

For this reason, pharmacists will come across more patients who use CBD and CBD-related products, yet many pharmacists may remain uncertain of how to manage their patients’ medication regimen along with CBD.  The research and data on CBD are new and more is coming out over time, making this a dynamic medicinal agent on which to stay informed.

The Evidence Behind CBD’s Use for Sleep

The endocannabinoid system (ECS) is an extensive, endogenous signaling system with many elements that are still being discovered as research progresses. In consideration of the fact that the ECS is modulated by diet, sleep, exercise, and stress, researchers believe that the modulation of ECS may hold therapeutic promise for a diverse scope of diseases, one of which is insomnia.2

Specifically, a study published in Current Psychiatry Reports demonstrated that CBD may hold promise for rapid-eye movement (REM) sleep behavior disorder, but there are mixed results and the research is still in its infancy.3

In a more robust literature review of studies exploring sleep and CBD published in Experimental and Clinical Psychopharmacology, the authors found that in the studies they assessed, sleep was often a secondary outcome, the study sample sizes were small, and many of the studies were short-term in nature. The authors of the review concluded that drawing any conclusions from these studies would be difficult. 4

A retrospective case study published in the Permanente Journal revealed that out of 72 adults who took CBD on a regular basis in a psychiatric clinic, 48 (66.7%) of them had improved sleep scores and 57 (79.2%) had reduced anxiety scores, both after the first month. The results fluctuated over time and the benefits diminished once supplementation was stopped.5

This supports a larger study, published in Medicines, which followed 409 patients taking cannabis (not CBD) and found a 4.5-point reduction on a 0 to 10 visual analog scale of their sleep symptoms.6

Overall, the data behind the use of CBD and sleep are new and in the beginning stages of development. Small studies over a short period of time do not provide conclusive evidence for the recommendation of CBD for sleep, though larger studies do seem to indicate there may be benefit for patients with insomnia. 

However, more research is needed regarding the specific ways that CBD can affect sleep, the implications of long-term use, and interactions it may have with other medications.  Finally, with CBD being a health and dietary supplement, several brands have entered the market, and so the gold standard product or brand has not yet been identified. 

At the moment, pharmacists should recommend to their patients to choose a brand of CBD that is reputable. A search on the Better Business Bureau and the FDA’s CFSAN Adverse Event Reporting System can provide information on the product’s reliability. 

Additionally, patients should be urged to take only one kind of product, to start taking it on its own so that adverse events (AEs) can be more easily identified, and to stop taking it and seek medical attention if AEs do develop, such as excessive somnolence, diarrhea, fatigue, and vomiting.

More patients may start taking or seeking CBD in their desire to achieve their optimal health. Pharmacists are the ideal health care practitioners to educate patients on these products and provide up-to-date information as it becomes available.

REFERENCES
  1. US Food and Drug Administration. Hemp Production and the 2018 Farm Bill. July 25, 2019. fda.gov/news-events/congressional-testimony/hemp-production-and-2018-farm-bill-07252019. Accessed October 13, 2020.
  2. Corroon J, Felice JF. The Endocannabinoid System and its Modulation by Cannabidiol (CBD). Altern Ther Health Med. 2019: 25(S2), 6-14. pubmed.ncbi.nlm.nih.gov/31202198/.
  3. Babson KA, Sottile J, Morabito D. Cannabis, Cannabinoids, and Sleep: a Review of the Literature. Curr Psychiatry Rep. 2017: 19(4), 2 doi: 10.1007/s11920-017-0775-9.
  4. Kuhathasan N, Dufort A, MacKillop J, et al. The use of cannabinoids for sleep: A critical review on clinical trials. Exp Clin Psychopharmacol. 2019: 27(4), 383-401. doi: 10.1037/pha0000285.
  5. Shannon S, Lewis N, Lee H, Hughes S. Cannabidiol in Anxiety and Sleep: A Large Case Series. Perm J. 2019: 23, 18-41. doi: 10.7812/TPP/18-041.
  6. Vigil JM, Stith SS, Diviant JP, et al. Effectiveness of Raw, Natural Medical Cannabis flower for Treating Insomnia under Naturalistic Conditions. Medicines. 2018: 5(3), 75. doi: 10.3390/medicines5030075.