We were puzzled by the 2018 American Academy of Sleep Medicine (AASM) position statement recommending obstructive sleep apnea (OSA) be struck from the list of medical conditions for state medical cannabis programs on account of unreliable delivery methods and insufficient evidence of treatment effectiveness, tolerability and safety.1 While positive airway pressure (PAP) will likely remain the gold standard therapy for OSA in the foreseeable future, there should be room for studying and integrating pharmacologic treatment strategies—not just endorsing expensive devices—that can lead to improved and more personalized disease modification. The contrary AASM stance bans members from recommending potential medical alternatives—specifically admonishing cannabis-based therapies—but also implying that failure of PAP in OSA is not an option, even though device nonadherence occurs in roughly half of the patients to whom it is initially prescribed. The AASM stance also implies that AASM affiliates had best be in lockstep with OSA-coupled diagnostic testing and device-driven management at accredited sleep centers because the alternative of ceding the management of patients with OSA who are nonadherent to PAP therapy is not allowed by the position statement authors1 (including FDA-approved medications [ie, dronabinol] studied for off-label indications).
Carley et al.,2 in an elegant placebo-controlled randomized clinical trial in patients with moderate or severe OSA found opposite results debunking the criticisms of the AASM's primary assertions including: Epworth Sleepiness Scale scores were reduced in the treatment group; the incidence of adverse events was not significantly different from placebo; and there was no evidence of decreased tolerability as measured by missed doses after 6 weeks of treatment using a 10 mg dose of dronabinol delivered reliably and safely in a pill form taken orally 1 hour before bedtime. Moreover, with respect to documenting alleged harms that outweigh benefits for medical cannabis therapies (including synthetic extracts like dronabinol) to justify the position statement, the authors of the AASM position statement1 fail to cite any relevant evidence to substantiate their ethical claims despite the existing context of ample medical cannabis research reported in humans.3 This glaring failure may further erode organizational credibility and may be the driving force behind patients with OSA seeking out cannabis program affiliates to discuss alternatives therapies especially when standard treatment is challenged by non-adherence and a nondisclosure policy pertaining to medical cannabis becomes the new norm of accredited sleep centers across the United States.
Work for this study was performed at The Heller School for Social Policy and Management, Brandeis University, Waltham, MA. All authors have viewed and approved the manuscript. The authors report no conflicts of interest.
Schears RM, Fischer AC, Hodge WA. Medical cannabis and AASM position statement: the don't ask, don't tell wishing well. J Clin Sleep Med. 2018;14(10):1811.
Ramar K, Rosen IM, Kirsch DB, et al. Medical cannabis and the treatment of obstructive sleep apnea: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2018;14(4):679–681. [PubMed Central][PubMed]
Carley DW, Prasad B, Reide KJ, et al. Pharmacotherapy of apnea by cannabimimetic enhancement, the PACE clinical trial: effects of dronabinol in obstructive sleep apnea. Sleep. 2018;41(1)
National Academies of Science, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of the Evidence and Recommendations for Research. Washington, DC: The National Academies Press; 2017.