NIGHTIME PAIN

BY MATT JACKSON, PHD

With chronic pain, getting a good night’s sleep can be a constant battle. Pain assaults sleep on two fronts, the first being easier to guess: nighttime pain. Just moving in the night can jar you awake with pain disrupting your sleep cycle, causing health problems that worsen over time. 1,2 Adults over the age of 65 who experience nighttime pain at least 3 times a week are 6 times more likely to feel excessively sleepy the next day, 3 and persistent insomnia can cause depression, anxiety, and an increased risk for accidents and being absent at work or school. 1

Before you jump in and say pain medications might help, the second thing disrupting sleep is more subtle: side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin can cause gastroesophageal reflux disease. 1 People often use proton pump inhibitors to manage side effects, but at night, stomach pH can get out of control and disrupt sleep with heartburn and acid indigestion. 1,4 Opioids are more potent for pain relief, but they are even worse for sleep.

Researchers monitored patients taking opioids for advanced cancer, and they found opioids lim-

ited deep sleep, the time when your muscles relax and your brainwaves finally slow down. If you miss out on deep sleep in the first few hours of a night, you might just wake up and go right back to bed. 5 These sleep disruptions can worsen pain levels over time, subverting the whole point of opioids, and contribute to mental health problems such as depression. 1

As the national opioid epidemic has generated more honest discussion about the addictiveness and side effects of opioids, many patients have turned to medical cannabis for chronic pain relief and help sleeping. This is not the first time in history either. Cannabis was used as an herbal sleep remedy in ancient Indian Ayurveda tradition, and when cannabis was brought to Western medicine in the 1850s, doctors widely prescribed cannabis for sleep when conditions such as pain interfered. 1 Now we have a wide range of cannabis cultivars, so it's no longer as simple as saying cannabis is good for sleep. We must consider how different cannabinoids affect our ECS and work to relieve conditions such as pain and disrupted sleep.

THC is the primary psychoactive cannabinoid and can ease the pain pathway of the central nervous system. 1 THC can be effective in relieving chronic pain, and in the short-term, THC can help you fall asleep faster and make you feel like you're sleeping better. For example, patients with fibromyalgia found THC to be more effective than the prescription sleep drug amitriptyline.

The other most abundant cannabinoid, CBD, can relieve pain, reduce inflammation, and scavenge oxidants without any psychoactive effects. 1 At low doses, CBD can be stimulating and increase wakefulness, but as dosage increases, CBD can be sedating. For example, a high dose of 160 mg CBD per day can increase sleep time and decrease sleep disruptions. 2 When treating nighttime pain specifically, most research has combined the sedating effects of CBD with pain-relief from THC.

The leader in nighttime pain research has been GW Pharmaceuticals, the company that achieved FDA approval for using CBD to treat drug-resistant epilepsy. GW has another product for treating chronic pain in multiple sclerosis, Sativex, which is a whole plant extract with an equal ratio of THC and CBD. 1 In clinical trials, GW amassed reports from more than 2,000 people with a total of 1,000 patient years of Sativex exposure, and they demonstrated extracts with 1:1 THC to CBD consistently improved sleep for patients with chronic

pain. 1,2 Over 80% of patients reported their sleep was satisfactory, good, or very good through 124 weeks of use, without any evidence of tolerance build-up or dysregulated sleep–wake cycles. 1

While Sativex is not yet approved by the FDA, we can borrow the cumulative evidence to suggest which cannabis cultivars and/or products to try for nighttime pain. THC can help manage pain symptoms and initiate sleep, but CBD is an important component to maintain long-term sleep rhythms. So, you could first try extracts with a 1:1 THC to CBD ratio. You might also find some benefit using cannabis high in CBD and low in THC with terpenoids that are sedative, such as terpineol. 1 When it comes to how much you should take, when you should take it, and if you should take a low dose of CBD in the morning, that’s up to you.

IN THE 1850S, DOCTORS WIDELY PRESCRIBED CANNABIS FOR SLEEP WHEN CONDITIONS SUCH AS PAIN INTERFERED...

Insomnia from chronic nighttime pain can drain daytime energy, so it's easy to finally get a few nights of pain relief with cannabis but not notice imbalanced sleep rhythms when sleep has been disrupted for so long. I would strongly suggest anyone using cannabis for nighttime pain should take careful notes on what they tried, for how long, and how they felt. Note how long it took to get to sleep, if you woke up in the middle of the night, how long you slept, if you felt rested in the morning, and how your energy levels were the next day. Were you alert and ready to go, or did you feel drowsy in the middle of the day? If so, that could be a sign you’re taking too much THC, or the balance of CBD to THC is too low. Sativex clearly showed us patients with chronic pain can manage nighttime pain and sleep with cannabis products, but it might take a little experimentation to figure out how cannabis can work best for you.