Hadley Larson, seen on Thursday, March 1, 2018 in Sonoma, Calif., uses CBD tinctures to help reduce anxiety from the Wine Country fires and to help her sleep. | Photo by Russell Yip
Last year, Sonoma winemaker Hadley Larson’s mother had a stroke, a relative attempted suicide twice, and the Wine Country fires forced her to evacuate with her son while her husband stayed to guard their home.
Months of anxiety and nights of five hours of sleep led to outbursts of “random rage,” panic attacks and suicidal thoughts, she said. A psychiatrist in November recommended anti-depressants and anti-anxiety drugs, but when Larson, wary of side effects, asked him about using cannabis instead, his answer surprised her. “I will tell you,” she recalled him saying, “that that is where the research is headed.”
Within days of ditching the prescriptions in favor of a tincture of cannabidiol, or CBD, at bedtime, she was a new woman. The non-psychoactive cannabis substance helped to calm her racing thoughts, allowing her to nod off within 45 minutes, rather than ruminating for hours, and her anxiety subsided, too.
“I found the miracle drug — I’m sleeping, I feel happier, I feel grounded,” Larson said on a recent weekday.
“I’m telling every mom I know about CBD.”
Recreational cannabis laws are accelerating Americans’ switch away from sleeping drugs with addictive, dangerous qualities or painkillers that allow sleep to a non-toxic, herbal alternative. Cannabis is bringing relief to some who suffer from a variety of sleep disorders, with some doctors advocating it. But some mainstream medical practitioners, citing a lack of research and evidence, are reluctant to recommend the botanical as a pharmaceutical-type medicine.
“Almost every clinical study that’s looked at cannabis-based medicines has shown an improvement in sleep,” said Dr. Ethan Russo, one of the world’s leading cannabis researchers. To say otherwise, he said, is “to be staring in a deep hole — a deep hole of ignorance.”
Russo, a Seattle-area neurologist and the director of research and development at the International Cannabis and Cannabinoids Institute in Prague, has spent 22 years studying cannabis — 11 of them with GW Pharmaceuticals in Great Britain — and conducted clinical trials with a cannabis-based pharmaceutical, Sativex, which is an approved medicine in 29 countries outside the United States.
Others in the medical field are not comfortable with recommending cannabis to their patients, at least right now.
Dr. Fiona Barwick, a clinical assistant professor at Stanford Sleep Medicine, said the dearth of clinical research on cannabis in the United States is a deterrent. Patients of hers inexperienced in cannabis use have ended up in the emergency room with hallucinations or racing heartbeats from ingesting too much cannabis or feeling intense anxiety about the experience.
For insomnia, she recommends cognitive behavioral therapy, “the front-line recommendation from every major organization, based on decades of research conducted and results.”
Cannabis, Barwick thinks, “has enormous potential. The possible intersection between the endocannabinoid system and the circadian system is fascinating to me. It’s just too early to be making any recommendations or conclusions.”
It was Russo who pioneered the idea in 2001 that medical conditions such as migraine, fibromyalgia and irritable bowel syndrome could be based on deficiencies in the body’s regulator of electrochemical signaling in the nerves — the endocannabinoid system. The system produces its own endogenous cannabis-like chemicals to activate it, but it can also be triggered by plant-based cannabinoids such as those found in cannabis. Russo believes plant cannabinoids can correct endocannabinoid deficiencies within the human body, in much the way a key fits into a lock and opens a door.
“For better or worse, most doctors don’t know very much about cannabis and next to nothing about the endocannabinoid system — it isn’t taught in medical school or residency,” said Russo. “If that were not enough, we have to overcome a really pronounced inherent prejudice here because of decades of propaganda about the dangers of cannabis by the government.”
The American Sleep Association estimates that 50 million people nationwide suffer from sleep disorders, with insomnia, sleep apnea, narcolepsy, sleep deprivation and snoring the most common. In 2013, the most current figures available, roughly 1in 6 people reported filling one or more prescriptions for psychiatric drugs, and more than eight in 10 reported long-term use, according to a review published in JAMA Internal Medicine in February 2017. The top five drugs prescribed, according to the review, were listed as Zoloft (for depression, anxiety), Celexa (depression), Xanax (anxiety), Ambien (insomnia) and Prozac (depression, anxiety).
1 in 6 Americans using psychiatric drugs for sleep or pain
17,648 —The number of scientific articles in the PubMed database containing the word “cannabis”
32 percent decrease in the amount of obstructive sleep apnea in a study with patients using synthetic cannabis
4.8 million — The number of Americans using Ambien for sleep in 2013, according to a 2017 study
61 percentage of seniors at Rossmoor retirement community’s cannabis club who in a recent survey reported using cannabis for sleep
Despite their ubiquity, sleeping pills carry serious side effects like amnesia and sleepwalking (or even sleep-driving). With opioids, patients can develop tolerance that leads to higher doses and even death by overdose, when the drug tells the respiratory centers of the brain to turn off — and the body stops breathing. Small wonder patients are looking for alternatives.
Cannabis has been used medicinally for thousands of years. It was used in the 1700s for skin conditions, incontinence and nausea. It was regulated as a drug in the United States in the mid-1930s and outlawed by the federal Controlled Substances Act of 1970. An Israeli chemist studying cannabis for its medical properties discovered tetrahydrocannabinol, or THC, with psychoactive properties, in 1964, and the discovery of CBD, cannabidiol, followed. Today, researchers know of eight major cannabinoids and at least 100 others.
Since the 1980s, researchers have discovered cannabinoid receptors in the brain, gut, spleen, liver, heart, kidneys, bones, blood vessels, lymph cells and reproductive organs. They now know that almost all vertebrates contain an endocannabinoid system, and that plant-based cannabinoids such as THC and CBD can affect them.
Cannabis comes in two basic types: sativas, which have stimulating qualities, and indicas, which create a sense of idleness or lethargy. Indicas are most commonly recommended for sleep.
Russo said research shows that THC causes sedation, while CBD, often recommended for people who do not want THC’s euphoria, is actually a stimulant. Both THC and CBD, he said, are affected by terpenes in the plant — fragrant oils that give it various aromas and also contribute to its effects. Myrcene has a sedating effect, pinene is said to counteract short-term memory impairment, and limonene, with the scent of citrus, has a brightening, antidepressant effect, he said.
A common refrain is that cannabis is not well-researched.
Many studies and trials have been conducted in other parts of the world, including Israel, Canada and Europe. One study by Russo and colleagues published in Chemistry & Biodiversity in 2007 showed that trials of Sativex, a synthetic cannabis with equal parts THC and CBD, helped 40 to 50 percent of 2,000 patients with multiple sclerosis, cancer, rheumatoid arthritis and other pain attain “good or very good sleep quality,” with no tolerance or need for dosage increases, when followed for up to four years.
A review of all cannabis sleep research to date, published in the April 2017 issue of Current Psychiatry Reports, noted, among other things, that cannabis is useful for quelling nightmares of veterans with post-traumatic stress disorder by reducing rapid eye movement sleep, or the REM sleep that occurs during the dream cycle. And a clinical trial at Northwestern Medicine and the University of Illinois at Chicago showed that a synthetic cannabis called dronabinol reduced obstructive sleep apnea by 32 percent by targeting the brain and neurotransmitters that control upper airway muscles, according to findings published in December in the journal SLEEP.
San Rafael, Calif. psychiatrist and author Dr. Michael Moskowitz believes cannabis is better for sleep than Lunesta, Ambien or other hypnotic drugs. | Photo by Liz Hafalia
Another strong advocate of cannabis for sleep is San Rafael psychiatrist Michael Moskowitz, who specializes in chronic pain and is author of “Medical Cannabis: A Guide for Patients, Practitioners and Caregivers.” “There are more than 13,000 articles in medical literature in Pubmed in the last 10 years on built-in endocannabinoids and more than 8,000 articles on the plant,” he said. “Scientific literature is bursting. These are not in crummy journals.”
But Moskowitz, who was an assistant professor of pain medicine in the anesthesiology department at UC Davis for 12 years, knows that federal bans against the study of Schedule I drugs have made it difficult to research cannabis in the United States. Moreover, the American medical system favors randomized, double-blind controlled trials that test one variable in a drug. With 100 or more pharmacologically active cannabinoids in cannabis, studies isolating one compound are next to impossible.
Case studies, while less rigorously scientific, offer hope, Moskowitz thinks. His own case study of 157 of his own patients began in January 2016 and looked at cannabis as a medicine for pain, stress and sleep. It showed that 87 percent reported less pain and 81.5 percent reported better sleep over an 18-month period. The patients ranged in age from 20 to 99, with most over 50. Most were white; two-thirds were female.
Cannabis does not act like sleeping pills, which are hypnotic drugs. Instead, it is an agent that reduces symptoms that interfere with sleep, such as pain, anxiety or urinary frequency. Moskowitz said that there is no lethal dose and that the cure for overconsumption is a nap.
“I would rather have someone on a high THC tincture at night than Lunesta, Ambien or any of these hypnotic sleeping agents,” Moskowitz said. “Cannabis is the best sleeping medicine I’ve ever used with patients.”
Psychiatrist and pain specialist Dr. Michael H Moskowitz, (right), uses sound therapy on his patient, former KFRC and KOIT radio host Bobby Ocean (left), and recommends cannabis for sleep and to reduce the use of opioids for pain. | Photo by Liz Hafalia
One of them is Suzie Olmsted, 61, a former professor at the San Francisco Art Institute. Bone loss in her hips, muscle atrophy, two hip replacements and arthritis led to acute pain that forced her into a wheelchair. A pump in her abdomen administers a powerful opioid to her spinal column to ease pain and assist with sleep, but for eight years, she was only able to doze throughout the night.
In 2014, she started seeing Moskowitz. Beginning with guided meditation and shiatsu, and then moving to CBD capsules with a small amount of THC, she found that her pain decreased, she cut her opioid use by 75 percent, she began walking, and she now sleeps five to seven hours a night on average.
“They say marijuana is the gateway drug to heroin,” Olmsted said. “I see it as a gateway drug away from opioids.”
In San Jose, Chris Johnson, 56, a biotech instrumentation consultant, was treated for stage 4 colon cancer in 2010. Five years later, he developed an inoperable tumor in his pelvis, which presses painfully on a nerve in his leg, affects his ability to walk and has not responded to treatment. A year ago, he developed restless leg syndrome, which caused his leg to jerk in bed at night every 10 seconds, keeping him and his wife awake for hours. A doctor recommended low-dose edibles with 5 mg of THC and 30 mg of CBD for the spasms. Johnson also wanted to cut back on his doses of 100 mg a day of oxycodone for pain, which left him in a haze and feeling depressed.
Johnson, long resistant to the idea of THC and getting high, relented.
“When your options are limited, you open your mind and say, ‘What the hell? It can’t be any worse than what I’m already enduring,” Johnson said.
The small amount of THC did not make him high, but almost immediately, the strength and frequency of the spasms decreased and sometimes stopped entirely. Instead of five or six hours of sleep, he’s now getting 10 to 12 hours a night.
The difference in his quality of life is “huge,” he said. “When it’s lights out, I can pretty much guarantee I’ll fall asleep instead of rolling around. I feel energetic and engaged as opposed to just sort of getting by, dragging, low-energy, depressed.”
For San Francisco veterans, cannabis has been life-changing, too. At a recent meeting of Operation EVAC, a nonprofit that holds talk therapy sessions and educates veterans about cannabis, a 34-year-old former Army infantryman who served in Afghanistan from 2012 to 2013 was one of several who told the group that he has bad dreams several times a week.
The previous evening, he’d had alcohol before bed instead of indica-dominant edibles, and ended up with nightmares.
“That night, I was defusing an IED (improvised explosive device), which I’ve never done, and I don’t know how to do, and it blew up in my face,” he said, declining to give his name for privacy reasons. “Cannabis makes the dreams less violent. They end up being more fun, like trippy, stoney, happy dreams.”
Bobby Ocean shows some of his cannabis medication including preheated ACDC flower in a capsule. He also uses a Black Beauty tincture. | Photo by Liz Hafalia
And at Rossmoor, a senior community of 10,000 residents in Walnut Creek, a recent survey of the 800 members of its cannabis club yielded 204 responses, which showed that 61 percent use cannabis to improve sleep, 61 percent for pain control, 30 percent for stress, 28 percent for pleasure or relaxation and 25 percent for other medical conditions. (Respondents were able to check more than one box, so the numbers add up to more than 100 percent.)
Most said they used non-psychoactive tinctures or edibles, and 94 percent said cannabis was helpful to them, while 6 percent said it was not helpful, according to Diane Beeson, the research and development coordinator and medical sociologist at Rossmoor.
But cannabis does not work for everyone.
Crickette Brown Glad, a 60-year-old philanthropist from San Mateo, began using a CBD tincture before bed in August, hoping to get relief from the pain of nocturnal, unconscious jaw clenching that left her with headaches in the morning.
A day after using the tincture, she developed vertigo. She tried a vaporizer pen with CBD, and developed such extreme vertigo that she could not walk upright and “had to crab-walk to the bathroom.” She used CBD balm on her father’s arthritic hands. The next day, she developed vertigo. She tried a CBD pill, too, and developed vertigo again.
“I said, ‘That’s it — I’ve tried every form. Cannabis is not for me,’” she recalled. “It may not affect anybody else that way, but that’s how it affects me.”
And East Bay cannabis clinician Eloise Theisen, a nurse practitioner who specializes in geriatrics, advises against CBD for sleep, saying, like Russo, that it can act as a stimulant, especially in women.
Of the 4,000 patients she has seen since 2014, about 85 percent have had sleep success with cannabis with THC, which she recommends in 2.5-mg doses. Older patients, she has found, do better with vaporizer pens than other tech gadgets, and inhalation yields effects within minutes, versus the hour or more for edibles. The result for people who are getting more sleep is tangible: “More mental clarity, more energy, less anxiety,” Theisen said.
Other side effects of THC can include anxiety, dry mouth, or difficulty concentrating. Cannabis can make people temporarily dizzy, or forgetful, and can potentially be habit-forming.
Dr. Donald Abrams, a UCSF oncologist who has been advocating cannabis as medicine since treating AIDS patients in 1992, understands that the lack of clinical trials is a deterrent, since modern physicians are taught to base their decisions on evidence, and not anecdotes.
He said the goal of developing cannabis as a pharmaceutical may not be realistic, but that does not mean cannabis is any less effective.
“I’ve been a doctor for 40 years and have never admitted patients to the hospital for complications of marijuana use, but the number of patients I’ve cared for as an oncologist and internist with consequences of alcohol and tobacco use is uncountable — and that’s not even talking about heroin, cocaine and methamphetamine,” Abrams said. “It’s a botanical, if you will. Cannabis works. It’s a very effective medicine.”
Larson, the Sonoma winemaker, is a believer.
“There are so many people I’ve given it to — people who have never walked into a dispensary or smoked,” Larson said. “I’m spreading the gospel.”
Carolyne Zinko is a San Francisco Chronicle staff writer. E-mail: firstname.lastname@example.org