Since we largely utilize non-invasive sampling techniques, at least for the fish samples, performing quantitative measures is a challenge. Nonetheless, future studies should focus on developing non-invasive methods for accessing the quantitative measures of microbial quantities in both the BE and the fish mucous.Marijuana is one of the most commonly used drugs in the United States. It is now well known that individuals report self-treating with MJ for a number of medical and psychiatric symptoms, most commonly PTSD, pain, anxiety, and insomnia. The availability of MJ to treat these symptoms has been increasing, due in part to changes in laws related to MJ use. In the United States, MJ has been legalized in four states, decriminalized in 16 states, and there are now 23 states that have medical marijuana legalization. Many individuals using MJ medicinally or for recreational purposes use MJ for insomnia. This is despite the research suggesting that treatment seeking and non-treatment seeking 6 individuals report disturbed sleep when they stop using MJ and a only a small portion report a reduction of related symptoms as a primary benefit of use.Marijuana use is most prevalent in the United States among 18-25 year olds with approximately 32% of non-college and 35% of college-attending persons reporting past year use, and 19% of emerging adults reporting past month marijuana us. Young adults use MJ for recreational reasons, but some also use MJ for sleep difficulties. An estimated 7.3% of individuals aged 18-29 meet ICD-10 or DSM-IV criteria for the diagnosis of insomnia. In a community sample of over four thousand 18-25 year olds, 29.3% scored above the clinical cut-off on the Pittsburgh Sleep Quality Index . Thus, roll bench about 30% of individuals in this age group complain of sleep disturbance, although only one-fourth of these meet formal diagnostic criteria.
Insomnia has been associated with both self-reported impairments in daytime functioning and lost productivity. The biopsychosocial changes of young adulthood affecting sleep are well known and may contribute to MJ use. As individuals begin to live more independently, there may be fewer restrictions on sleep schedules, particularly parent-set bedtimes. Many choose to stay awake later at night to socialize or to meet academic demands. Individuals with an evening “chronotype,” who prefer to be awake late into the evening, have been shown to have more problems with reward functioning. Evening chronotypes have also demonstrated higher depression scores 16 , suicidal thoughts, more impaired work and other activities, higher paranoid symptoms, and higher anxiety, compared to a morningness-type group. Thus, the pattern of MJ use in young adults may be influenced by an interplay between changes in sleep patterns, chronotype, and mood. To date, literature on the effects of marijuana on sleep a young adult sample have been somewhat limited. While objective sleep indices have been studied in middle aged Veterans who are heavy MJ users, only one study has examined objective indices of nocturnal sleep and daytime sleepiness the following day in a community sample of young adults. In that study, 8 healthy volunteers participated in a double-blind and placebo-controlled study with either: 1) 15 mg D-9-tetrahydrocannabinol , 2) 5 mg THC combined with 5 mg cannabidiol , 3) 15 mg THC combined with 15 mg CBD or 4) placebo 22 via oromucosal spray one hour before bedtime. THC in addition to CBD was used because of the different effects associated with each compound, i.e. CBD is not as centrally activatinglike THC and has useful therapeutic/anticonvulsant properties. Participants underwent polysomnography and then sleep and morning functioning were evaluated. Nighttime sleep slightly worsened with 15 mg CBD and next day performance was impaired with 15 mg THC. This study highlights the effect of MJ on both nighttime sleep and daytime functioning.
If the relationship between MJ use and sleep disturbance in persons who are not seeking treatment for substance use disorders is substantial and documented to affect daytime function, it could have major public health significance. Health officials could publicize the relationship of MJ and sleep, primary care and behavioral health workers could highlight this information during office visits for insomnia, and drug treatment providers could meaningfully target sleep among MJ users who do seek treatment.Epidemiological studies have found associations between MJ use and insomnia over time. Adolescents, in particular, who used any illicit drug were 2.6 times more likely to report a sleep problem than those who remained substance free 24. In a nationally representative sample, adolescents with insomnia were 1.8 times as likely to report MJ use compared to adolescents without insomnia. Across ages, about one in five persons who use MJ report insomnia . This is significantly higher than the rate of insomnia diagnosed in persons not using MJ 25 which is approximately one in ten.While these epidemiological studies are informative and suggest co-occurrence, they do not inform us regarding the relationship of level of MJ use to sleep effect, or as to common versus reciprocal etiology. Participants were co-recruited from a larger study on individuals who use alcohol and marijuana between March 2012 and September 2013 through on-line advertisements in Craig’s List, Facebook, flyers, word-of-mouth, radio advertisements, and newspaper advertisements targeted at the Rhode Island/southeastern Massachusetts area. These methods are free services, widely known and used, and easy to access from a computer or smartphone. The advertisement for this study read, “Adults between 18 and 29, do you use marijuana?” You may be eligible to participate in a research study,” and asked interested persons to call the study telephone number listed. Exclusion criteria were: 1) past month cocaine, opioid, benzodiazepine, barbiturate, inhalant, PCP, hallucinogen, or stimulant use, 2) more than one episode of binge drinking in the past month.
We permitted inclusion of one binge episode because of the small number of participants who had no episodes of binge drinking in the last month, 3) night shift work, 4) self-reported diagnosis of schizophrenia, bipolar disorder, or attention deficit hyperactivity disorder, 5) lack of stable housing, 6) current suicidal ideation, and 7) past month use of sleep medication or antidepressants. We also recruited an age-matched control group who reported no MJ use in the last month. A total of 1307 persons aged 18-29 who reported using marijuana at least once a month were screened by phone for eligibility. Of these, 1052 were ineligible,drying rack cannabis due to more than one recent binge drinking episode. Other reasons for exclusion included use of other drugs , mental disorder diagnosis , currently being treated for depression , suicidal ideation , and unstable housing . Of the 146 eligible participants, 8 could not be reached to schedule a baseline appointment, 4 refused participation, and 35 did not come in for their baseline appointment. Ninety-nine consented to participate in the study; one person was excluded from participation after consent due to non-compliance with study protocols and limited cooperation with study staff. This study was approved by the Institutional Review Boards of Butler Hospital and the University of Michigan.All participants were administered the patient version of the Structured Clinical Interview for DSM-IV 27 at baseline to assess for current marijuana dependence only in the last year. During the baseline interview, a Time Line Follow Back 28was conducted to assess for MJ use over the past 4 weeks. On each day of MJ use, participants were asked how many minutes they smoked MJ. Participants were provided with the following instructions: “We would like you to look on this calendar and let us know how much time you spent using marijuana each day so we can write that in. We are also interested in knowing what time each day you used marijuana.” The day was divided into 4 six-hour quadrants. Daily smokers were defined as persons smoking MJ at least six days per week, and non-daily smokers were persons who smoked on at least 1 day in the past month to up to 5 days per week. Non-users were participants who had not smoked MJ in the last month.The basis for using minutes of marijuana as an outcome was because it is very difficult to ascertain in the naturalistic setting exactly how much THC the participant is ingesting. To clarify this measure further, we made frequency of use in days and meeting a diagnosis of dependence as our secondary measures. In looking at the validity of our chosen outcome measure, we did find support from concurrent measures of MJ use frequency. The spearman rank correlation between average minutes of MJ use during the two-week evaluation period and the percentage of days using MJ during that same period was r=0.88 .
The median was 25.18 and inter-quartile range was 12.90-62.91. The correlation between average minutes of MJ use during the twoweek evaluation period and a baseline DSM-IV diagnosis of Cannabis Dependence was r=0.33 . Although not significant statistically, those with a diagnosis of Cannabis Dependence reported an average of 42 as compared to an average of 24 among those without a diagnosis, a moderate effect size . Pittsburgh Sleep Quality Index —The Pittsburgh Sleep Quality Index is a self-rated questionnaire which assesses general sleep quality and sleep disturbances over a 1-month time period. Nineteen individual items generate seven “component” scores: subjective sleep quality; sleep latency; sleep duration; habitual sleep efficiency; sleep disturbances; use of sleeping medication and daytime dysfunction. The sum of scores for these seven components yields one global score. A global PSQI score greater than 5 has been used to define sleep disturbance.Insomnia Severity Index—The Insomnia Severity Index is a seven-item selfreport questionnaire assessing the nature, severity, and impact of insomnia in the past month. Dimensions evaluated are: severity of sleep onset, sleep maintenance, and early morning awakening problems, sleep dissatisfaction, interference of sleep difficulties with daytime functioning, noticeability of sleep problems by others, and distress caused by the sleep difficulties. A 5-point Likert scale is used to rate each item , yielding a total score ranging from 0 to 28. We used a cut off ≥10 because this score has been shown to be optimal for detecting insomnia cases in a community sample . Epworth Sleepiness Scale—The Epworth Sleepiness Scale is an 8-item questionnaire assessing the level of daytime sleepiness. Respondents rate their likelihood to fall asleep or doze off on a scale of 0-3 in 8 different situations that may induce sleepiness . A score of 10 or greater is considered problematic daytime sleepiness, with a score of 18 signifying severe daytime sleepiness. The Morningness Eveningness Questionnaire —Smith’s MEQ is a 13- item questionnaire that assesses individual time of day preference for morning or evening activities, such as bed- and rise-times, and the clock time of becoming fully awake. This questionnaire measures behavioral temporal preference with high reliability, validity, and cross-cultural utility . Scores range from 13-52. Scores ≤22 indicate an eveningness preference, 23-43 indicated intermediate , and scores ≥44 indicate morningness.Patient Health Questionnaire-9—The PHQ9 is a 9- item questionnaire that inquires about how often mood symptoms were bothersome to the participant in the past two weeks. Participants respond on a Likert scale between 0-3, with 0 = not at all, 1=several days, 2=more than half the days, and 3=nearly every day. Total scores from 5-9 indicate mild symptoms of depression, 10-14 moderate symptoms, 15-19 moderately severe, and 20-27 severe. PHQ9 is a reliable and well validated scale.The Psychiatric Diagnostic Screening Questionnaire—To obtain information about anxiety, we used the brief 10-item PDSQ scale to measure generalized anxiety disorder. The PDSQ refers to the past 2 weeks. Participants responded to 10 questions about their anxiety with either no or yes . Higher scores reflect more anxiety symptoms.We conducted analyses on the enrolled participants that provided baseline interview responses. A hierarchical multiple regression analysis was performed to explore whether MJ use group predicted scores on sleep, daytime sleepiness, and chronotype questionnaires. Given that the high rate of unemployment in the sample may impact sleep behaviors and the possibility of gender differences in MJ use patterns, all models included gender and employment status as planned covariates. Because anxiety 40 and depression 19 are related to both marijuana use and sleep, we followed up our initial evaluations with models that controlled for these potential confounds in our analyses.