Can smoking marijuana help with restless leg syndrome?

Cannabis for Restless Legs Syndrome: Not Recommended

Based on the most recent and highest quality evidence, cannabis is not recommended for treating restless legs syndrome, as it lacks proven efficacy and carries significant risks including psychiatric complications, cannabis use disorder, and impaired driving safety. 1

Evidence Against Cannabis Use

The 2025 American Academy of Sleep Medicine clinical practice guideline for RLS treatment does not include cannabis among recommended therapies, despite comprehensive evaluation of available treatments. 1 This omission is notable given the guideline's thorough review of both established and alternative treatments.

The only controlled trial examining cannabidiol (CBD) specifically for RLS in Parkinson's disease patients found no reduction in RLS severity compared to placebo, with doses ranging from 75-300 mg over 14 weeks. 2 This represents the highest quality evidence available and directly contradicts anecdotal reports of benefit.

Significant Safety Concerns

Cannabis use carries substantial risks that outweigh any theoretical benefits:

• Psychiatric risks: Cannabis may trigger or exacerbate depressive disorders and other psychiatric conditions, with 10% of chronic users developing cannabis use disorder characterized by inability to reduce use despite negative consequences. 1

• Driving safety: Cannabis users are more than twice as likely to be involved in motor vehicle crashes, with fatal accidents involving cannabis increasing from 9.0% in 2000 to 21.5% in 2018. 1

• Cardiovascular effects: Potential arrhythmias and orthostatic hypotension may occur, particularly problematic in older adults with RLS. 1

• Cannabis hyperemesis syndrome: High-dose use can cause severe cyclic vomiting requiring hot showers for relief. 1

Evidence-Based Alternatives with Proven Efficacy

The American Academy of Sleep Medicine provides clear first-line recommendations:

First-line pharmacological treatment:

• Alpha-2-delta ligands (gabapentin, gabapentin enacarbil, or pregabalin) receive strong recommendations with moderate certainty of evidence for RLS treatment. 3, 4 These agents improve RLS symptoms, sleep quality, and pain without the augmentation risk of dopaminergic agents.

Iron therapy:

• Check serum ferritin and transferrin saturation in all RLS patients, ideally in the morning after avoiding iron supplements for 24 hours. 3
• IV ferric carboxymaltose receives a strong recommendation for patients with ferritin ≤75 ng/mL or transferrin saturation <20%. 3
• Oral ferrous sulfate is conditionally recommended for appropriate iron parameters. 3

Second-line options for refractory cases:

• Extended-release oxycodone and other opioids are conditionally recommended, particularly when treating augmentation from dopaminergic agents, with evidence showing relatively low abuse risk in appropriately screened patients. 1, 3

Clinical Pitfalls to Avoid

• Do not use dopamine agonists (pramipexole, ropinirole, rotigotine) as standard therapy due to significant augmentation risk with long-term use, despite short-term efficacy. 1, 3

• Avoid medications that worsen RLS: Antihistamines, serotonergic antidepressants, antipsychotics, and bupropion can exacerbate symptoms. 3

• Screen for obstructive sleep apnea: Untreated OSA can worsen RLS and increases risks when combining alpha-2-delta ligands with opioids due to enhanced respiratory depression. 1

Treatment Algorithm

1. Assess iron status first: Ferritin ≤75 ng/mL or transferrin saturation <20% warrants iron supplementation. 3

2. Initiate alpha-2-delta ligand: Gabapentin, gabapentin enacarbil, or pregabalin as first-line pharmacotherapy. 3, 4

3. Consider IV iron: If oral iron fails or rapid improvement needed in iron-deficient patients. 3

4. Reserve opioids: For refractory cases or augmentation management after careful screening for abuse risk. 3, 5

Cannabis remains an unproven intervention with documented harms and no place in evidence-based RLS management. 1, 2