How to treat insomnia induced by cannabis use?

Treatment of Cannabis-Induced Insomnia

The primary treatment for insomnia caused by marijuana use is discontinuation of cannabis followed by Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line intervention. 1

Understanding the Diagnosis

Cannabis-induced insomnia is classified as "Insomnia Due to a Drug or Substance," where sleep disruption occurs during periods of cannabis use or during discontinuation. 1 The insomnia is expected to resolve or substantially improve once the substance is stopped and discontinuation effects subside. 1

A critical distinction: Cannabis withdrawal itself causes insomnia as a prominent symptom, along with irritability and headaches. 1 This means patients may experience worsening insomnia initially after stopping cannabis, which typically improves over time.

Treatment Algorithm

Step 1: Cannabis Cessation

• Discontinue cannabis use, as this is the definitive treatment for substance-induced insomnia. 1
• Counsel patients that withdrawal-related insomnia is temporary and expected to improve as discontinuation effects subside. 1

Step 2: First-Line Treatment - CBT-I

• Initiate CBT-I immediately as the standard of care for insomnia, with strong evidence for sustained improvements lasting up to 2 years. 2, 3
• CBT-I remains effective in cannabis users and should include: 4
  • Sleep restriction therapy to improve sleep efficiency 2, 3
  • Stimulus control to strengthen bed-sleep associations 2, 3
  • Cognitive therapy to address distorted beliefs about sleep 2, 3
  • Sleep hygiene education (though insufficient as monotherapy) 2
• Treatment typically requires 4-8 sessions over 6 weeks. 2
• Key evidence: CBT-I is effective in reducing insomnia symptoms regardless of ongoing cannabis use, though cessation remains the goal. 4

Step 3: Pharmacotherapy (Only if CBT-I Insufficient)

If insomnia persists after 2-4 weeks of CBT-I and cannabis cessation, consider adding: 3, 5

• Low-dose trazodone (25-50mg at bedtime) as first pharmacologic option, with lower dependence risk than benzodiazepines. 3, 5
• Alternative: Low-dose doxepin (3-6mg), which has FDA approval for insomnia with minimal anticholinergic effects at low doses. 3, 5

Critical Pitfalls to Avoid

• Do not prescribe hypnotics as first-line treatment before attempting CBT-I, as this violates guideline recommendations and provides less durable benefit. 2
• Avoid benzodiazepines due to dependence risk, abuse potential, and cognitive impairment, particularly problematic in patients with substance use history. 5
• Do not rely on sleep hygiene education alone, as it lacks efficacy as a single intervention. 2
• Avoid adding multiple sedating medications simultaneously, which increases daytime sedation risk. 3

Monitoring and Follow-Up

• Use sleep logs to document sleep latency, awakenings, total sleep time, and sleep efficiency. 3
• Reassess after 2-4 weeks of intervention to evaluate improvement in sleep parameters and daytime functioning. 3
• If insomnia persists despite these interventions, refer to a sleep specialist for further evaluation. 3

Important Context on Cannabis and Sleep

While patients commonly use cannabis for insomnia symptoms 1, the evidence for efficacy is contradictory and insufficient. 6, 7 Regular cannabis use leads to withdrawal that profoundly alters sleep 6, creating a cycle where the substance used to treat insomnia ultimately perpetuates it. 1 Brief Behavioral Treatment for Insomnia has shown promise in reducing both insomnia symptoms and cannabis-related problems in trauma-exposed young adults. 8