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Official websites use. Share sensitive information only on official, secure websites. Corresponding author: William W. Stoops, Ph. People who use cocaine experience numerous sleep problems and often use cannabis to mitigate these problems. However, co-using cocaine and cannabis may result in worse sleep outcomes when compared to using cocaine only. The current study examined group differences in subjective sleep outcomes among people who use cocaine and people who co-use cocaine and cannabis. Participants were 82 individuals with cocaine use disorder who were enrolled in a randomized clinical trial for cocaine treatment. Analysis of covariance and Kruskal-Wallis tests were used to compare sleep outcomes between participants with urine samples that tested positive for both cocaine and cannabis at baseline, those who tested positive for cocaine only, and those who tested negative for all drugs. Total reported sleep time was highest among those with a drug negative urine, followed by those with a cocaine positive urine and those who tested positive for cocaine and cannabis. There were no differences in perceived sleep quality, difficulty falling asleep, or daytime alertness between groups. People who co-use cocaine and cannabis may report reduced sleep time relative to those who only use cocaine. Co-use of cannabis may exacerbate sleep difficulties in people who use cocaine by decreasing total sleep time, although it is important to note that the groups each reported similar sleep quality. Implications for treatment and directions for future research are discussed. In , approximately one million people in the U. This issue has received little attention in the literature. Understanding sleep differences between people who only use cocaine and those who co-use cocaine and cannabis can inform sleep-related needs for those entering drug treatment. Therefore, the current study aimed to examine group differences in subjective sleep outcomes related to total sleep time and perceived sleep quality among people who use cocaine and people who co-use cocaine and cannabis prior to enrolling in treatment for cocaine use disorder. Existing research demonstrates the negative effects of cocaine use on sleep outcomes. Despite physiological sleep changes, cocaine users experiencing withdrawal typically do not report problems with sleep latency, total sleep time, or sleep satisfaction. Sleep disturbances and misperceptions after cocaine cessation have implications for treatment outcomes. Scholars have proposed that sleep disturbance is a risk factor for relapse, 15 as reduced sleep may lead to greater vulnerability for cocaine craving. Pre-clinical evidence suggests that sleep reduction impedes the extinction of previous cocaine-environment conditioning in rats. For example, sleep deficits among cocaine users negatively affect learning processes such as memory consolidation and motor sequence tasks. Therefore, it is important to broaden our understanding of factors that may exacerbate sleep disturbances among cocaine users seeking treatment. One way that sleep concerns are managed by people who use cocaine is by using cannabis. In addition to improving subjective reports of difficulty falling asleep, cannabis use has been cited as a therapeutic way to reduce cocaine-related cravings and symptoms of paranoia, fear, distrust, and aggressiveness. Evidence suggests that cannabinoids, chemical compounds present in cannabis, may provide a therapeutic benefit to reducing cocaine-induced anxiety and seizures. Therefore, the current study seeks to examine group differences in subjective sleep outcomes based on biological indicators of cocaine use or cocaine and cannabis co-use i. Data for the current study were derived from baseline measures of an ongoing randomized clinical trial examining health outcomes associated with reductions in cocaine use NCT In order to be eligible, participants had to be years old, provide a cocaine positive urine sample during screening, currently meet DSM-5 criteria for CUD, have a urine drug screen that is positive for cocaine during initial screening, be seeking treatment for cocaine use, and be able to commit to a week intervention and week follow-up. Testing was completed in a research laboratory at the University of Kentucky in Lexington, KY, and each test outcome was verified by two separate research staff. Urinalysis indicated the presence of three groups. Three individuals tested positive for cannabis only; due to small sample size, these participants were removed from further analysis. The St. Select items were used to assess the following:. Participants were asked to report their total sleep duration the day prior to their assessment. During the day, yesterday? Both sleep from the previous night and during the previous day were used, as many participants reported working overnight and sleeping during the day. Number of criteria were totaled to indicate level of CUD severity for each participant. Participant descriptive statistics were calculated to compare characteristics of the three groups. Chi-square analyses and ANOVA were used to examine group differences in categorical and continuous descriptive variables. Non-parametric Kruskal Wallis tests were used to compare differences in ratings of sleep quality, daytime alertness, and difficulty falling asleep due to these variables being measured on an ordinal scale. Participants ranged in age from 23 to 61 years old. Total sleep time ranged from minutes to minutes among participants. Data screening for outliers led to the removal of two cases in the COC group with total sleep times greater than minutes from final analysis. Prior to completing analysis, tests for normality of standardized residuals and interaction between the covariate and IV were conducted. The NONE group had a difficulty falling asleep median score of 1. The current study examined differences in total sleep time and perceived sleep quality among people with CUD who were entering treatment for cocaine cessation. Each group was comparable with regards to race, sex, education level, and number of CUD criteria reported. Participants who co-used cocaine and cannabis reported sleeping more than two hours less on average than those who did not test positive for cocaine or cannabis, and approximately one hour less than those who tested positive for cocaine only. This suggests co-use of cocaine and cannabis may exacerbate sleep problems more than cocaine use alone, contrary to intended mitigation of sleep problems that many co-users seek. Our findings indicate differences in total sleep time that can have clinically significant implications for cocaine use treatment. The combined impact of cocaine reduction and potential increases in cannabis use may continue to compound sleep problems and influence treatment success. All groups perceived their sleep to be of similar quality, reported little difficulty falling asleep, and reported feeling alert during the day regardless of urinalysis results. Our results are consistent with prior research showing discrepancies in total sleep time and perceived sleep quality among people who use cocaine. It may be of benefit to consider addressing healthy sleep during the beginning of CUD treatment regardless of participant self-reports of sleep quality, particularly among people who report co-use of cannabis. There are numerous nonpharmacological techniques that could be incorporated into substance use treatment to aid in sleep. It may be that some of the other compounds found in cannabis are a detriment to sleep over time while other compounds such as cannabidiol have other therapeutic benefits. This prompts the need for further study on the effects of cannabidiol on sleep among people who use cocaine. These preliminary results from baseline data of a randomized control trial indicate a critical intervention point for those who co-use cocaine and cannabis. There are also limitations that raise important future directions. First, the sample sizes of the three groups were relatively small and uneven, which may suggest the need to interpret our study results with caution. Second, although there is evidence to suggest people who use cocaine also use cannabis to mitigate the effects of cocaine on sleep, the current study did not measure whether participants used the two substances in the same day or at the same time. The use of biological confirmation to demonstrate recent cannabis and cocaine use has methodological strengths over self-report measures. However, the urinalysis used for the current study was unable to provide a quantitative estimate of THC levels. Future research on sleep outcomes should incorporate assessment of simultaneous use of cocaine and cannabis i. Further study is needed to determine how the combined effect of cocaine and cannabis on sleep as determined by urinalysis differs from cannabis alone. Another limitation is the current study used subjective measures of total sleep time and sleep quality. These estimations may be less accurate than polysomnography PSG results; however, evidence suggests subjective and objective measures of sleep highly correlate during the first week of withdrawal. The current study is also limited in that it does not assess other objective measures of sleep quality, such as sleep architecture. Evidence indicates that both chronic cocaine use and chronic cannabis use impact sleep stages, including time spent in slow wave sleep and REM sleep stages. Lastly, this study is cross-sectional and does not examine changes in sleep throughout the course of treatment. However, in demonstrating potential differences in total sleep time at treatment enrollment, our study highlights a plausible direction for future research by monitoring differences in sleep depending on frequency of cocaine use and whether one co-uses cocaine and cannabis. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. As a library, NLM provides access to scientific literature. Pharmacol Biochem Behav. Published in final edited form as: Pharmacol Biochem Behav. Find articles by Paris B Wheeler. Jardin N Dogan , Ed. Find articles by Jardin N Dogan. Danelle Stevens-Watkins , Ph. Find articles by Danelle Stevens-Watkins. William W Stoops , Ph. Find articles by William W Stoops. Issue date Feb. PMC Copyright notice. The publisher's version of this article is available at Pharmacol Biochem Behav. Open in a new tab. Declarations of interest: none. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. African American. Years of Education. Cocaine Use- last 30 days. Cannabis Use- last 30 days. Total Sleep Time minutes. Difficulty Falling Asleep. Daytime Alertness.

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The Arab defeat in the war brought Palestinians under Israeli occupation. A half-century later, Palestinians have tried it all—from civilian resistance to armed uprisings, from suicide terrorism to missile warfare, from peace negotiations to international diplomacy—to no avail. A Palestinian state in the West Bank looks less and less viable. The question is today inevitable: does Israel want peace? While Netanyahu did undertake negotiations at different points during the Barack Obama presidency, he was never willing to come close to the proposals that had been made by previous leftwing Israeli governments, which the Palestinians had anyway rejected. Netanyahu also introduced the pre-condition of asking the Palestinians to recognize Israel as a Jewish state—which they could not accept—in order to both neutralize the demand for a Palestinian right of return and eventually derail the whole peace process. Much of the failure to make peace between Israelis and Palestinians has to do with the tragic inconsistencies of the Oslo Accord upon which the entire peace process was built. Essentially built on the unequal relations between the occupied and the occupier, Oslo was bound to crash into the rock of conflicting national dreams. Yet it is not too late to reach a settlement: 80 percent of Israeli settlers are still concentrated in blocks of settlements adjacent to the Green Line. The conventional premise has always been that these could be annexed to Israel provided they are swapped with land on the other side of the Green Line. Both the Barak and the Olmert governments proposed such swaps. The hallmark of the post-Oslo years was the fatal symmetry between settlements and terrorism. Loyal to the old Zionist philosophy according to which the last kindergarten also defines the political border, the Israelis tried to influence the nature of any final agreement with a hectic policy of settlement expansion into Palestinian lands. The Palestinians responded with terrorism. The negotiating process for a final settlement fell victim also to the conflicting interpretations as to what exactly were the exact premises upon which it was built. The Israelis came to the negotiations with the conviction inherent in the letter of the Oslo Accords that this was an open-ended process where no preconceived solutions existed. Neither Yitzhak Rabin nor Shimon Peres ever thought that the peace process would usher in a full-fledged Palestinian state. Constructive ambiguity facilitated an agreement in Oslo at the price of creating potentially irreconcilable misconceptions with regard to the final settlement. A Two-State Trap Unlike peace efforts with the Arab states, especially in the case of Egypt and Jordan, which have been strictly political undertakings based on restitution of territory, peacemaking with the Palestinians is not just a matter of land in exchange for peace. It is an attempt to almost break the genetic code of the Arab-Israeli conflict, and perhaps even of the Jewish-Muslim dispute, by touching upon religious and historical rights of ownership. Even so, why has peace in Palestine been such a tragically elusive enterprise? Almost every opinion study in both Israel and Palestine has always shown an unequivocal support for the two-state solution to the Israeli-Palestinian conundrum. Yet, at the moment of truth when reasonable solutions—the Clinton Peace Parameters of , and Ehud Olmert peace proposals of —were on the table, the delusion of some better deal in the future prevailed. Today, while Israel drifts rightward and away from peace initiatives, Palestinians lack leadership and a legitimate partner for peacemaking. The tragedy of the Israeli-Palestinian peace conundrum is that while the two-state solution is where the salvation of both national movements truly lies, it is at the same time highly unattractive to them. A mini-Palestinian state would be sandwiched between two skeptical neighbors, Israel and Jordan, both deeply suspicious of its future evolution. Nor would the Palestinian state that Israel could agree to be able to satisfy the Palestinian constituent ethos of the Right of Return and its quest for justice. Hence, such a state might be seen as illegitimate even among sizable segments of the Palestinian nation at home and in the diaspora. The Palestinian national movement lacks today a coherent and cohesive sense of purpose. The two-state idea is not a constituent article at the root of the national Palestinian narrative; its political father and its major source of legitimacy, Yasser Arafat, is no longer there to give the necessary cohesion to a movement that has lost its way, that is fragmented, and whose political spinal cord, Fatah, the party that led the shift to the idea of partition, is broken, practically nonexistent. The carriers of the two-state idea, the Oslo leadership, represent the monumental deception that came with it, and they suffer from a very dangerous deficit of legitimacy. As for the Israelis, a two-state solution would mean a return to what Abba Eban, not exactly a hawk, defined as Auschwitz borders. Moreover, such a settlement would entail a sociopolitical earthquake of untold dimensions, for it would require a massive evacuation of settlers, and might lead to civil strife and military disobedience in an army replete these days with national-religious officers and troops intimately attached to the settlement movement in Judea and Samaria. And all this in order to go back to borders nobody has a special nostalgia for with a neighbor nobody truly trusts. The Israelis do not believe the Palestinians would be able to prevent Hamas from taking over the West Bank and becoming an outpost of Iran only a few kilometers from Tel Aviv. And neither believes that Israel will be able to dismantle and relocate more than , Messianic settlers who live beyond the so-called settlement blocs. Nor can the old concept of a Palestinian demilitarized state satisfy Israel today because the new weapons can easily bypass any monitoring mechanisms. Given the lessons from Gaza, the security requirements of Israel will be extremely difficult to reconcile with the Palestinian idea of what is exactly a sovereign state. The settlers movement continues as strong as ever. Settlers and their allies on the Israeli right are by no means alone in their conviction that Zionism always flew in the face of reality; it succeeded because it ignored reality and will continue to do so. Underlying the very serious question of the settlements is a an even more serious problem that has to do with the involvement of the entire Israeli body politic in maintaining and continuously expanding a regime of coercion and discrimination in the territories. This is a regime of dominance that has the drive and traits of permanence. It would require a truly historic leadership to dismantle and get rid of. Exposed to indiscriminate waves of suicide terrorism, the Israelis lost any hope of a negotiated settlement and in their despair succumbed to a new self-defeating political religion, that of unilateral disengagement. Humiliated by Israeli retribution, with the backbone of their society broken, and in response to the sad vicissitudes of deficient governance, the Palestinians embraced the militant organization Hamas as a legitimate option. The Intifada forced the Israelis to turn their back to the Palestinians, erase them from their consciousness, imprison them behind impenetrable walls while keeping for themselves the essential parts of the land required for their settlements and rising security needs. But, with no Palestinian partner willing to accept peace based on Israeli land grabbing, it was the specter of the loss of the Jewish demographic predominance in historical Palestine, an inevitable concomitant of the death of the two-state idea, that gave life to the concept of unilateral disengagement from populated Palestinian areas. Its pattern of peace diplomacy—direct negotiations between the parties under U. A successful peace diplomacy requires at times the transformation of the mediator into a manipulator and an arm-twister. Too frequently it acted as if the process of negotiation operates on its own inherent logic, independent of considerations of power and coercion. By delinking force from diplomacy, Washington gave the parties in the conflict the sense that American power lacked resolve and conviction. America continues to be an indispensable actor in the Middle East and beyond, but it has lost the awe-inspiring drive of the past and its willingness to use coercive diplomacy in its quest for a new order. It no longer intimidates, not even allies and clients such as Israel and the Palestinian Authority. In this peace process no stone has been left unturned, no idea untried. The solutions are all there. The deal now depends on the diplomatic perseverance and resourcefulness of the mediators, and on the political will and courage of leaders to take unpopular decisions. Unless both parties trim their conditions on key contentious issues, the Trump peace process would end in the normal, tragic anticlimax we have been used to. A man of short fuses, Trump does not have the patience for details. But in the Israel-Palestine situation where historical narratives are so overwhelming, and geography so small, details do matter. No small narcissist himself, Trump would soon discover that the narcissism of minor differences that derailed previous negotiations would compromise his process as well. To abandon the comfort zone they have been living in, Israeli and Palestinian leaders must be confronted with both a tempting peace plan and the threat of a massive American and all-Arab pressure. Unless this happens, the parties would prefer, as they always did, to retreat to their normal refuge from unpopular decisions, the protective warmth of their moral consensus. It should be clear by now that the United States cannot solve the Israeli-Palestinian conflict by itself just as it cannot solve single-handedly the Iranian nuclear dispute, the North Korean crisis, or the mega-tragedy that is the Syrian civil war. In the last twenty years, Washington excelled in forming international coalitions for wars in the Middle East. For a change, it could now try to form an international alliance for Middle East peace. The new paradigm needs to be that of an essentially international solution for Palestine. Led by the United States, the international community would then have to devise a strategy for the implementation of this peace plan. The new paradigm requires broadening the scope of the peace process: the objective should no longer be only about Israeli-Palestinian peace but about a regional settlement between Israel and its Arab neighbors. This should be so if only because the future Palestinian state would be in no condition to offer Israel the kind of security it requires. That was very well understood by the initiators of the all-Arab Peace Initiative, which neither Israel nor the United States gave the attention it deserved. One would have expected that the surprising strategic intimacy between Israel and the major Arab powers in the region—a result of the ill-fated Arab Spring, and the rise of the ominous threats of Iran and Islamist terrorism—would pave the way for the revitalization of the Arab Peace Initiative. The same applies to the Sunni Gulf dynasties and Egypt, now in close security cooperation with Israel. Israel looks today far freer than in the past to ignore Palestinian rights and turn its back on the requirements of a genuine peace process. Moreover, the Jewish state now enjoys a global clout unprecedented in its history. An Israeli foreign policy that was for years hostage to one single issue, Palestine, has acquired a maneuver space it hardly ever had. To future-proof itself against mounting popular pressure in the West, Israel has been looking elsewhere with extraordinary success for economic, and ultimately political, partners. It now does more trade with the once-implacably hostile Asian giants—China, India and Japan—than with the United States. A marriage of convenience has created a tripartite geopolitical bloc, a counterweight to Turkey, between Israel, Greece, and Cyprus. As the prime minister himself edges Israel toward an illiberal democracy, Netanyahu trusts that the changing political balance in Europe will shield Israel against EU initiatives on Palestine. Indeed, it was thanks to the stance of that very illiberal East European axis that the recent EU directives on exports from the occupied territories came out far more attenuated than initially planned by Brussels. Of course not—the problem was always about the fatally corrosive effects that the suppression of Palestine has on Israeli society. The Asian giants do not share with Israel the same outlook on the world to a degree that is essential for a true strategic alliance. But this essential truth would acquire its meaning only once political change is produced in Israel and the Palestinian national movement recovers its unity and sense of purpose. This would still allow a peace agreement based on land swaps between Israel and a future Palestinian state. The alternative scenarios to a two-state solution are all dark and gloomy. Such a state would live in a permanent state of civil war. Saudi ambassador to the United States, Bandar Bin Sultan, even believed it to be a crime against the Palestinian people. The Israeli side might then try to get away with unilateral moves that would help it salvage its international image, while at the same time responding to genuine Israeli concerns. The nature of these steps would greatly depend on the structure of the Israeli coalition at the time. Such an Israeli unilateral Convergence Plan would be utterly rejected by the Palestinians if only because this would turn the West Bank into a replica of the Gaza situation with Israel controlling all the outer accesses to the territories, first and foremost the Jordan Valley. Essentially, one needs to bear in mind that Zionism, even rightwing Zionism as Ariel Sharon has shown in his unilateral withdrawal from Gaza, has always given pre-eminence to demography over territory. Whenever Zionism had to opt between more land and a less homogeneous Jewish majority, or less land with a Jewish majority, it opted for the latter. The same pattern was reflected in the concept of settlement blocs created by Labor Party after , and its opposition to what Yitzhak Rabin called political settlements deep in the West Bank. Some 30 percent of these settlers have been polled to say that they would be ready to be compensated into moving to Israel proper. The hardline, ideological settlers would resist evacuation, and the battle would be far tougher than in the case of Gaza. The battle for a bilateral peace should not be abandoned. For, against the ominous predictions of the specter of civil war looming over Israel if a massive dismantling of settlements were carried out, the mostly peaceful Gaza disengagement proved to be anticlimactic. The notion finally percolated through to Israelis that this Jewish republic of settlers on the golden sands of Gaza and the hilltops of Judea and Samaria has become an unbearable burden that has drained the resources of the nation and doomed it to a suicidal confrontation with the Palestinians. Once considered a patriotic vanguard, the settlers now became an obstacle that needed to be removed, an entanglement that needed to be untied, if Israel were to maintain its Jewish and democratic character. In the summer of , it looked as though Israel was a society mature enough to face the formidable challenge of defining its final borders without cataclysmic upheaval. The precedent was established and, for the first time since , the State of Israel challenged Eretz-Israel and survived. An Israeli-Palestinian peace, which is a vital necessity for the Palestinian nation, is no less so for the Israeli occupier. Occupation has diminished the moral credentials of Israel among the family of civilized nations. Practices applied in the occupied territories spill over to this side of the West Bank, eroding the foundations of Israeli democracy. It either degenerates into an apartheid state where a Jewish minority oppresses the Palestinian majority in a state of permanent civil war, or it switches away from its rightward drift and works for a two-state solution, before it is too late. Shlomo Ben Ami is an Israeli politician, diplomat, and professor of history. Read More. 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