Narcolepsy is a chronic sleep disorder that presents as a disruption of the normal sleep-wake cycles and is associated with disturbances in REM sleep (rapid eye movement). Only about one in two thousand have this disease and the cause is unknown but may be related to low levels of a neurotransmitter orexin or hypocretin.
The research on cannabinoids and sleep is in its infancy and studies are limited, and are not randomized and clinically controlled. These studies also involve limited sample sizes, lack proper follow up, and involve a number of different cannabinoids and dosage techniques. The wide array of compounds in the cannabis plant make it complex to determine which ingredient specifically may be responsible for any given effect in regard to sleep studies. However, some reproducible effects and guidelines have been seen in general and can be reported on. It is known that the endocannabinoid system plays a role in mediating circadian rhythms and the sleep-wakeful cycle. Cannabis can help with the maintenance and promotion of sleep. Also noteworthy is that cannabis withdrawal syndrome can be characterized chiefly by one major effect – insomnia, lack of proper sleep, and vivid dreams. In fact, disturbed sleep can also last up to 45 days after cessation of cannabis use, making this the longest-lasting withdrawal symptom. Studies on narcolepsy and sleep must take into account the impact of different cannabinoid ratios, dosages, the timing of a given dose, and ingestion techniques, as well as subjective and objective determinations of sleep efficiency and patterns.
Narcolepsy usually appears in adolescence between the ages of 8 and 25. Symptoms usually include excessive daytime sleepiness (EDS) and disruptive sleep at night. Some patients experience cataplexy which is a sudden loss of muscle tone while awake resulting in a “drop attack” where one can fall over and collapse and be unable to move or speak. Patients remain conscious with cataplexy and this attack can be similar to having a seizure. However, there are no involuntary muscle movements like those which occur with epileptic seizures. It is postulated that in cataplexy the activity of neurons in the brainstem that are activated to inhibit movement during REM sleep somehow become activated while awake.
This disease is diagnosed by a physician based on a polysomnogram done while the patient is asleep, sleep latency testing while awake, or a test of orexin levels and hypocretin levels in spinal fluid. If these levels are shown to be low, these compounds can be administered in some cases in order to help treat the deficiency in narcoleptic patients.
Narcolepsy patients may have difficulty staying awake during daylight hours and can suddenly and quickly fall asleep. These involuntary episodes can be dangerous and unpredictable when they occur and can lead to serious consequences (i.e. falling asleep while driving). These episodes are usually short duration and can occur without warning. Narcolepsy can also lead to issues with concentration, memory loss, severe fatigue, lack of energy, and exhaustion.
Narcoleptic patients typically also have disrupted sleep at night and difficulty falling asleep or staying asleep. In addition, they may have vivid dreams that result in acting out while asleep, nightmares, hallucinations, involuntary leg movement that causes them to wake up, or sleepwalking and/or talking.
Currently, there is no cure for narcolepsy and it is usually treated by a psychiatrist, a team of medical specialists, and sleep doctors. There are several drugs that can be used including daytime stimulants Provigil, Nuvigil, Methylphenidate (Ritalin, Concerta), and amphetamines. At night Xyrem can be used to promote sleep, and also reduce daytime sleepiness and cataplexy. Antidepressants can also be used to combat daytime sleepiness and cataplexy. The drugs Prozac and Effexor are sometimes used, although the negative side effects can often limit their use.
Some studies of narcoleptics also indicate that they may have associated substance use disorders and self-medicate with marijuana, alcohol, narcotics and sleep-inducing drugs such as Trazadone, Ambien or Sonesta. These patients can also become habituated to amphetamines used during the day to help stay awake, as well as dependency on sleep meds at night. Abuse of these pharmacologic agents is minimized if proper medical and psychiatric care is also co-administered.
Cannabis can be used in several different ways as an adjunct to help treat the symptoms of this disease, although research is relatively scarce and disjointed. Attempts to induce sleep and promote restfulness at night is perhaps one avenue that can be employed. An Indica/high myrcene strain can be employed to induce sleep, along with the cannabinoid CBN (found in feel dreamy tincture). Also the sedative terpene linalool (from lavender) can also be effective in sleep promotion. For longer-lasting effects an edible, tincture or RSO (Rick Simpson Oil) can be employed compared to smoking or vaping. RSO can be a potent agent for sleep when delivered sublingually with the proper dose and timing, regardless of the THC/CBD ratio in the oil, but typically a higher THC ratio is more effective at inducing sleep. CBD is also a sedative agent in high dosages, but can be stimulating in small doses and perhaps used to combat daytime sleepiness if the dose is kept low (i.e. 5-10 mg.) CBD can also potentiate any pharmaceutical sleeping medications and allow either a lower dose or stronger effect with a regular dose. CBD in higher dose levels, for example, 25-100mg, can also help induce sleep by itself. There are reports from some of the patients under my care that there is a benefit by using a vape pen at night if they wake up in the middle of the night and want to return to sleep. This might be a vape pen with a 1:1 strain. Anecdotally marijuana or “pot brownies” almost always cause sleepiness and many individuals given them will report extreme fatigue and sleep for a long period sometimes waking up many hours later with a strong sedative hangover effect. Any hangover effect from cannabis can be reduced by using products in proper dosage and timing their ingestion, sometimes well before one wishes to go to sleep. THC can be an effective sleep-inducing agent, but usually, sleepiness occurs after the THC is metabolized and some is converted to CBN – cannabinol. THC can initially have a period of stimulation usually for one or two hours but then can cause sedation and fatigue after it is metabolized.
There is a wide variety of responses to cannabis and often opposite effects can be observed based on timing, dose, method of ingestion and the exact components. A given response should be tried and repeated over time as often paradoxical results can occur initially when using cannabis for sleep issues. The wide array of compounds in cannabis makes a given response difficult to analyze as to which ingredient is being effective for any given problem. Patients must experiment and be willing to try a host of products and techniques. Patients with Narcolepsy who use cannabis should attempt to regulate their sleep cycles with proven strains that work for them, and maintain a regular sleep schedule that is consistent. The Fit Bit HR Charge II is a biometric monitoring device that can be employed to monitor the duration and quality of sleep as well as record the 4 stages of sleep in graphic and numerical form. Those patients with narcolepsy may benefit from using this device by simply wearing it all the time and looking at their sleep patterns and times, both during the day and at night. In this fashion, some of the ingestion techniques, strains, and dosages of cannabis can be monitored in regards to the effect on their sleep duration and patterns. Interested patients who are new users starting with cannabis can also begin a medical journal to record observations and monitoring of their progress.
While cannabis and its derivatives play a certain role in sleep and well-being, the federal restrictions of cannabis as a schedule one substance have limited research and prevented additional studies on sleep issues including narcolepsy, insomnia, sleep apnea, and nightmares for those suffering from PTSD. Consequently, those using cannabis for narcolepsy and sleep issues are often left to their own resources and the advice of their medical cannabis certifier, as well as their own research available on-line and through articles and publications that may be available.
Dr. Stanley R. Manstof
12201 Greenridge Drive
Boyds, Md. 20841
*MMCC Certified Provider
*American Academy of Cannabis Physicians
*Member Americans for Safe Access
*Technical Writer and Editor
*Member Society of Cannabis Clinicians
*International Cannabinoid Research Society
*Certified Patient Caregiver
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