CBD for Relaxation and Sleep: Evidence-Based Recommendations
Current evidence does not support CBD as an effective treatment for insomnia or sleep disturbance, and it should not be recommended over established first-line therapies.
Why CBD Is Not Recommended
Insufficient Evidence for Sleep Improvement
A 2024 randomized controlled trial of 150 mg CBD nightly showed no significant difference from placebo for insomnia severity, sleep-onset latency, sleep efficiency, or wake after sleep onset 1.
A 2024 comparative effectiveness trial found that 15 mg CBD performed no better than 5 mg melatonin for sleep disturbance, and adding minor cannabinoids (CBN, CBC) provided no additional benefit 2.
A 2023 systematic review concluded that evidence is inadequate to support CBD for insomnia, noting that only 2 of 34 studies focused specifically on insomnia patients, most used non-validated measures, and objective sleep assessments were largely absent 3.
A 2020 systematic review stated there is insufficient evidence to support routine clinical use of cannabinoid therapies for any sleep disorder, citing lack of published research and moderate-to-high risk of bias in existing studies 4.
Guideline Recommendations Against Cannabis for Sleep
The 2024 ASCO guideline found only very small improvements in sleep among cancer patients (weighted mean difference of –0.19 on a 10-cm visual analog scale), with moderate certainty of evidence, and noted that benefits were smaller than those seen in non-cancer pain populations 5.
The 2024 American College of Physicians position paper notes that cannabis withdrawal symptoms include insomnia, suggesting that chronic use may worsen rather than improve sleep problems 5.
The only FDA-approved CBD medication (Epidiolex) is indicated solely for specific epilepsy syndromes, not for sleep or anxiety 5.
What Should Be Recommended Instead
First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)
The American Academy of Sleep Medicine and American College of Physicians strongly recommend CBT-I as the initial treatment for all adults with chronic insomnia, as it demonstrates superior long-term efficacy compared to medications with sustained benefits after discontinuation 5, 6.
CBT-I includes stimulus control therapy, sleep restriction therapy, relaxation techniques, and cognitive restructuring, and can be delivered through individual therapy, group sessions, telephone-based programs, or web-based modules 5.
Pharmacologic Options When CBT-I Is Insufficient
For sleep-onset insomnia:
- Zaleplon 10 mg (5 mg in elderly) has a very short half-life with minimal residual sedation 7, 6.
- Ramelteon 8 mg is preferred for patients with substance use history due to no abuse potential 7, 6.
- Zolpidem 10 mg (5 mg in elderly) reduces sleep-onset latency by approximately 25 minutes 7, 6.
For sleep-maintenance insomnia:
- Low-dose doxepin 3-6 mg reduces wake after sleep onset by 22-23 minutes with minimal anticholinergic effects and no abuse potential 7, 6.
- Suvorexant 10 mg (orexin receptor antagonist) reduces wake after sleep onset by 16-28 minutes 7, 6.
For combined sleep-onset and maintenance:
Critical Safety Considerations
All hypnotics should be used for the shortest duration possible (≤4 weeks for acute insomnia), as FDA labeling indicates short-term use and long-term safety data are limited 7, 6.
Pharmacotherapy should supplement, not replace, CBT-I, as behavioral interventions provide more sustained effects than medication alone 7, 6.
Monitor for complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating) and discontinue immediately if they occur 7, 6.
Common Pitfalls to Avoid
Using CBD based on anecdotal reports or marketing claims rather than evidence-based medicine—the available data show it performs no better than placebo or low-dose melatonin for sleep 1, 2, 3.
Failing to implement CBT-I before or alongside any pharmacotherapy, which leads to less durable benefits and higher risk of medication dependence 7, 6.
Recommending over-the-counter antihistamines (diphenhydramine) or herbal supplements (valerian), which lack efficacy data and carry significant safety concerns 7, 6.
Continuing pharmacotherapy long-term without periodic reassessment (every 2-4 weeks) to evaluate efficacy, side effects, and ongoing need 7, 6.