What Managed Care Needs to Know About Cannabinoids and Sleep: Mark Malesker, PharmD

Millions of Americans are already turning to cannabis products to manage sleep problems, often without telling their physicians.¹ According to a 2024 CDC survey of more than 31,500 adults, an estimated 4% of US adults use cannabis products most days or every day to aid their sleep, a figure that climbs to 5.5% among adults ages 18 to 35. Separately, a survey found that more than 80% of respondents reported reducing or discontinuing conventional sleep aids after initiating cannabis use.² As federal efforts to reschedule marijuana continue to be evaluated, pharmacy directors, pharmacy and therapeutics (P&T) committees, and managed care clinicians are under growing pressure to establish coverage and utilization policy in a landscape that remains far from settled.

At the American Academy of Sleep Medicine and Sleep Research Society (SLEEP) Annual Meeting in Baltimore, Maryland, Mark A. Malesker, PharmD, FCCP, FCCM, FASHP, BCPS, professor of pharmacy practice and medicine at Creighton University School of Pharmacy and Health Professions and clinical pharmacy specialist in pulmonary medicine and critical care at CHI Health Creighton University Medical Center, participated in a session examining cannabinoids and sleep from multiple angles: clinical evidence, safety risks, public safety, and policy implications.

The American Journal of Managed Care^® (AJMC^®) asked Malesker about what the current evidence supports and what it does not, and how managed care professionals should be approaching formulary and coverage decisions in this space.

This interview has been lightly edited for clarity.

AJMC: Your session at SLEEP 2026 covered cannabinoids and sleep from multiple angles. Can you give us an overview of what attendees were meant to take away and why this topic is particularly timely right now?

Malesker: THC [tetrahydrocannabinol]- and CBN [cannabinol]-containing products are likely to remain widely available and increasingly utilized, and many consumers seek these products without the guidance of health care professionals. Additional research is needed to better define the role of CBN in the management of sleep disorders and to establish its efficacy and safety. As medical marijuana undergoes reclassification, opportunities for expanded research may emerge, leading to a better understanding of both its therapeutic potential and associated health care challenges. The lack of standardized dosing and product consistency across cannabis formulations will continue to present challenges for formulary inclusion, insurance coverage, and clinical decision-making.

AJMC: Millions of patients are already using cannabis products to manage sleep problems, often without telling their physicians. From a clinical pharmacy standpoint, what does that reality mean before any formal coverage policy exists?

Malesker: The widespread use of cannabis products for sleep, often without the knowledge of health care providers, highlights the need for pharmacists to proactively assess cannabis use as part of routine medication reconciliation and patient counseling. While the evidence supporting the use of cannabis products for sleep disorders remains limited and inconsistent, patient interest and utilization continue to grow. As a result, pharmacists must balance the available evidence with real-world patient use when evaluating efficacy, safety, and potential drug interactions.

The absence of formal coverage policies does not eliminate the need for risk assessment and patient education. Pharmacists should engage patients in nonjudgmental discussions regarding cannabis use, evaluate for adverse effects such as next-day sedation, cognitive impairment, falls, and dependence, and consider potential pharmacokinetic drug interactions with other concurrent medications along with potential pharmacodynamic interactions with central nervous system depressants. Attention should be paid to older adults and patients with multiple comorbidities, who may be at greater risk for adverse outcomes.

Until more robust clinical evidence and standardized products become available, pharmacists should emphasize evidence-based sleep interventions, monitor patient-reported outcomes when cannabis products are used, and advocate for additional research to better define the role of cannabinoids in sleep disorders.

AJMC: There is a meaningful difference between cannabinoids helping patients fall asleep and producing genuinely restorative sleep. Does the current evidence support the idea that cannabinoids improve sleep quality, or are we mostly seeing a sedation effect?

Malesker: The current evidence suggests that cannabinoids may help some patients fall asleep more quickly and, in certain cases, increase total sleep time; however, there is insufficient evidence to conclude that they consistently improve restorative sleep quality. Much of the reported benefit appears to be related to their sedative properties rather than a demonstrated ability to normalize sleep architecture or enhance restorative stages of sleep.

Studies evaluating THC-containing products have shown mixed effects on sleep stages, with some data suggesting reductions in REM [rapid eye movement] sleep and variable effects on slow-wave sleep. While these changes may subjectively improve sleep for some individuals, it remains unclear whether they translate into better overall sleep quality, daytime functioning, or long-term health outcomes. Evidence for CBN is even more limited, with few well-controlled studies available to support claims that it specifically improves sleep quality.

From a clinical perspective, it is important to distinguish between inducing sleep and improving sleep. A patient who falls asleep more quickly due to sedation may not necessarily experience more restorative sleep or feel more rested the following day. Until larger, high-quality studies evaluate objective measures of sleep architecture, sleep quality, and daytime outcomes, the available evidence suggests that the observed benefits of cannabinoids are more consistent with a sedative effect than with a proven enhancement of restorative sleep.

AJMC: Drug-drug interactions are an area where pharmacists bring unique expertise. What are the most clinically significant interaction risks clinicians should be counseling patients about?

Malesker: When considering cannabis or cannabinoid use, pharmacists should review the patient's medication profile carefully. Clinicians should avoid or use cannabinoids with caution in combination with other central nervous system depressants—including benzodiazepines, opioids, sedating antidepressants, and sedative-hypnotics—due to the potential for additive sedation, cognitive impairment, and respiratory depression. Cannabis smoking may also induce CYP1A2 activity, potentially reducing serum concentrations of medications metabolized through this pathway, including olanzapine and clozapine.

CBD [cannabidiol] has a particularly significant interaction profile, acting as a strong inhibitor of CYP2C19, a moderate inhibitor of CYP3A4, and a weak-to-moderate inhibitor of CYP2D6. It may increase serum concentrations of SSRIs [selective serotonin reuptake inhibitors], warfarin, clobazam, eslicarbazepine, brivaracetam, tacrolimus, and cyclosporine. Patients receiving medications with narrow therapeutic indices—warfarin, tacrolimus, or cyclosporine in particular—should be monitored closely when CBD is initiated, discontinued, or dose-adjusted. Concomitant use of CBD and valproate has also been associated with an increased risk of hepatotoxicity and elevations in liver transaminases, warranting periodic monitoring of liver function.

THC is a weak inhibitor of CYP3A4 and CYP2C9; while clinically significant interactions are uncommon at typical doses, the risk increases with higher THC exposure and concurrent use of other CYP inhibitors. Given the expanding use of cannabinoid-containing products and the variability in product composition, pharmacists should routinely assess for potential drug interactions and monitor for changes in efficacy, adverse effects, and drug concentrations when appropriate.

AJMC: Pharmacy directors and P&T committees are increasingly being asked to take a position on medical cannabis. What evidence thresholds should they be looking for before a cannabinoid product earns a place in a formulary or coverage policy?

Malesker: Pharmacy directors and P&T committees should evaluate cannabinoid products using the same evidence-based standards applied to any other therapeutic agent. While patient demand and expanding state-level legalization have increased interest in medical cannabis, formulary inclusion and coverage decisions should be based on demonstrated efficacy, safety, product quality, and value.

P&T committees should carefully assess product consistency and quality. Unlike traditional pharmaceuticals, cannabis products can vary substantially in THC, CBN, and CBD content, purity, bioavailability, and manufacturing standards. Products supported by rigorous quality control measures, standardized dosing, and reliable labeling are more likely to be appropriate candidates for formulary consideration. Safety evaluations should include adverse effects, cognitive and psychomotor impairment, abuse potential, long-term safety, and clinically significant drug-drug interactions. Pharmacoeconomic analyses should also assess comparative effectiveness, health care utilization, and overall value relative to established therapies.

The regulatory landscape remains uncertain and continues to evolve. The next FDA commissioner will likely play a pivotal role in shaping cannabis rescheduling efforts and the future regulatory framework governing cannabinoid products—decisions that could significantly influence research opportunities, product standardization, prescribing practices, payer coverage, and formulary decision-making. Until a more robust evidence base and regulatory structure are established, P&T committees should remain cautious and apply the same rigorous standards of efficacy, safety, quality, and value expected of all formulary medications.

AJMC: If you had to identify the single most important takeaway for managed care professionals right now, what would it be?

Malesker: Cannabis use is associated with both acute and long-term adverse effects that managed care professionals cannot afford to overlook. Acutely, cannabis exposure can impair judgment, attention, reaction time, and motor coordination; it is associated with impaired driving ability and an increased risk of motor vehicle crashes. Cardiovascular effects include transient arrhythmias and, in susceptible individuals, an elevated short-term risk of myocardial infarction and stroke.

Over the long term, chronic cannabis use has been associated with cognitive impairment across multiple domains—including verbal episodic memory, working memory, attention, and decision-making—as well as increased risk of coronary artery disease, schizophrenia and other psychotic disorders, and chronic bronchitis symptoms. Some evidence also suggests a potential association with lung cancer risk.

For managed care professionals, the message is clear: the growing patient use of cannabinoids for sleep does not mean the evidence supports that use, and the safety profile warrants careful evaluation before any coverage or clinical endorsement.

References

1. Mykyta L, Elgaddal N, Warren A. Use of sleep aids among adults age 18 and older: United States, 2024. CDC. Last reviewed April 29, 2026. https://www.cdc.gov/nchs/data/hestat/hestat116.htm
2. Steuber A, Cuttler C. A large-scale survey of cannabis use for sleep: preferred products and perceived effects in comparison to over-the-counter and prescription sleep aids. Explor Med. 2023;4:709–719. https://doi.org/10.37349/emed.2023.00171