Cannabinoids in the Treatment of Long Covid

This informal CPD article, ‘Cannabinoids in the Treatment of Long Covid’, was provided by Jenner Medical Consultancy, formed by three healthcare professionals looking for a new challenge, with combined experience in the NHS, private practice, pharmacy, hospital, travel clinics and Cannabis Clinics, who want the name to not only be synonymous with training and embedding protocol but also as a go to for assistance and support.

Introduction

The 26th July 2018 became a milestone date in the recognition of the benefits of cannabinoids when the Home Secretary announced that following a recommendation from the chief medical officer and a ACMD review that cannabis derived medicinal products would be re-scheduled. Following this, in November 2018, the law changed to allow the prescribing of unlicensed cannabis-based products.

Prior to this change only two cannabis-based medicines were able to be prescribed in the UK, Sativex is licensed for use in the treatment of spasticity in MS and Epidyolex is licensed to be used in the treatment of seizures in children with Lennox Gastaut Syndrome, Pravet Syndrome and Tuberous Sclerosis Complex. The Medical Cannabis Access bill was introduced by Jeff Smith MP, it had its second reading on 10th December 2021 and its aim was to improve access to cannabis-based products.

Prescribing guidelines began to emerge, these found their roots in how cannabis had been used medicinally historically. The application of cannabis-based medication has been well documented as a reliable form of pain relief for centuries with evidence of its use found in ancient China, Egypt and The Roman Empire, (the word, sativa, comes from Latin and means "sown" or "cultivated”).

The past decade has seen a shift in the way the US cares for its veterans, previously little care and support was available, men returning from the conflict in Vietnam found little support existed for the condition that later became known as PTSD. Many found solace in marijuana which they discovered while there, which ostracised them further due to the times and the war on drugs campaign. Today more choice is offered and with 23 states legalising cannabis for medical/recreational use, this includes a socially accepted option of medicating with cannabis.

Further conditions were explored that it was widely agreed would benefit from the pain relieving, calming and anti-inflammatory properties of cannabinoids, a perusal of the leading UK clinics today will list more than 30 conditions cannabinoids, in their various forms, are successful in treating.

Long Covid

Coronavirus post-covid syndrome or Long Covid is the name given to a collection of symptoms that can last weeks, months or even years, the most commonly reported of which are:

• Extreme Tiredness
• Shortness of breath
• Loss of smell or taste
• Muscle aches

However, other symptoms are continually being recorded and can also include:

• Problems with recollection (brain fog)
• Chest tightness and heart palpitations
• Insomnia
• Dizziness
• Joint pain
• Depression and Anxiety
• Paresthesia
• Tinnitus
• Gastric anomalies
• Skin conditions

According to The Office for national Statistics (ONS), an estimated 2 million people in the UK were experiencing Long Covid in January 2023, with symptoms found to adversely affect the day to day activities of at least 75% of this figure.

People may have symptoms that are hard to explain and/or manage, some comparisons have been made with the symptoms of Myalgic Encephalo Myelitis/Chronic Fatigue Syndrome (ME/CFS). With this in mind, there is often a delay in diagnosis.

In general, Long Covid is more prevalent in people who have had a severe Covid-19 illness, people who are unvaccinated and people who have multiple infections with SARS-CoV-2. The virus that results in Covid-19. It has also been suggested that women aged between 40-50 are twice as likely as men of the same age group of developing Long Covid. Age continues to be a relevant factor. To date, more that £50 Million of government funding has been invested into research into Long Covid. One of these studies co funded by National Institute for Healthcare Research (NIHR) and UK Research and Innovation (UKRI) identified that sex, age and existing health problems increase the risk of Long Covid.

In July 2021 Long Covid was added as a recognised condition that could be accepted as a disability under the Americans with Disabilities act (ADA). The UK followed with Long Covid being added to the list of conditions accepted when claiming PIP or ESA payments.

With the often-associated symptoms of long Covid prescribing becomes a challenge. Dr Robert Bell, a Cardiologist at University College London Hospital, began monitoring patient complaints of a significant change to heart rate, primarily tachycardia upon exercise and a feeling of fatigue after.

“These people have a high resting heart rate of 100 just doing nothing, as soon as they try and exercise it will race up to 140, 150 even 180 and they are utterly exhausted for days after”.

It was found upon beginning treatment that some responded well to a Beta Blocker, research is still ongoing with Dr Claire Stevens, Senior Clinical Lecturer, saying that while exercise is helpful for some people with Long Covid, carefully paced exercise was important.

The Autonomic Nervous System (ANS) governs all the vital bodily functions that are involuntary i.e., breathing. When the ANS is harmed, it can result in problems from light-headedness and fainting to GI complications like bloating and abdominal pain, this condition is called Dysautonomia. A viral infection like Covid-19 can cause a specific variant of Dysautonomia called POTS. Postural Orthostatic Tachycardia Syndrome (POTS) often develops in Long Covid, with as many as 30% of sufferers meeting the criteria for POTS.

So how has Long Covid been managed to date? The answer is, unfortunately, with difficulty. Paxlovid is an antiviral medication that works by stopping the virus that causes Coronavirus from growing and spreading in the body, this is currently used to treat Covid-19 in high-risk patients, there is, at this time, little evidence to suggest it would be beneficial in treating Long Covid. In a 2020 researcher Carolyn Bramante, M.D., assistant professor of medicine at the University of Minnesota, examined electronic records from adults with type 2 diabetes or obesity. She found that women taking metformin before they developed COVID-19 were in most instances making a full recovery. These observational studies were enough to warrant further Trials. Metformin would have to deliver results in large random, placebo-controlled trials specifically designed to answer the question of whether it would be helpful for treating COVID-19.

Two such trials, TOGETHER and COVID-OUT, would give metformin the chance to prove itself as an effective COVID-19 treatment, these are ongoing.

At a primary care level today, the pain element as in muscle ache and painful stiff joints has been treated with prescription pain medication, ranging from NSAIDs to co-Dydramol, which can have detrimental results with long term use. The sleeplessness sees an emergence of Amitriptyline or Zopiclone, both of which can result in dizziness and brain fog which may exacerbate a symptom already present.

Add to this the need to treat anxiety, depression, skin problems and GI disturbances, and in most cases, you are looking at a scenario where patient needs are not being met or they are taking a daily cocktail of prescription medication. David Badcock, chief executive of Drug Science has made his views very clear:

“We need to address Long Covid, and quickly. Right now, physicians have very little they can offer to patients”.

An Alternative

The only question left is could patients suffering from Long Covid find relief in the form of Cannabinoids? In a recent review the researchers at Drug Science have identified multiple lines of evidence to support the use of cannabis-based medication for treating long Covid. Hannah Thurgur, senior research officer at Drug Science, spoke about the findings at Cannabis Europa earlier this year saying further Placebo-controlled trials would be beneficial to study the efficacy in more detail. Dr Dani Gordon, a specialist consultant, joined the discussion saying:

“I have been treating Chronic Complex conditions using integrative cannabinoid medication for over a decade.  Post viral or chronic fatigue is a bucket of conditions because its so complex and everyone is slightly different”.

With this complexity in mind, formulating a care plan for treating a patient suffering from Long Covid with cannabinoids may become very much a shared care approach which may see the patient seeing more than one consultant (if they are experiencing symptoms of pain accompanied by anxiety and/or depression). It should also include discussion at MDT level where the relevant consultants work together to provide optimum care. Cases would have to be treated individually as one patient diagnosed with Long Covid may have a very different experience to another with the same, on paper, diagnosis. Medication and dose would have to reflect this. Clinics should also be prepared to adjust the prescription at the one month follow up and after the shared care protocol has been initiated look at having a Long Covid register to continue monitoring.

Treatment, strain and dose is still very much at debating level at this time. Based on what is being prescribed for individual symptoms and as a rough guide, prescribing could start with a CBD dominant, like Noidecs T6:C200 or balanced oil like Khiron Khiriox T12:C14, with an Indica flower for breakthrough pain or to help with sleep. Some effective ones at the time of writing have high terpenes of Myrcene and beta-caryophyllene, which should also work on pain, stress and anxiety like Hellfire OG and Frosted Lemon Angel.

Cannabinoids prescribed by a specialist with expert care and safety netting in place can provide an excellent support option for Long Covid Sufferers.

We hope this article was helpful. For more information from Jenner Medical Consultancy, please visit their CPD Member Directory page. Alternatively, you can go to the CPD Industry Hubs for more articles, courses and events relevant to your Continuing Professional Development requirements.

References:

• https://ncats.nih.gov/pubs/features/can-metformin-treat-COVID-19-and-prevent-long-COVID-NCATS-and-partners-pursue-answers
• https://www.mirror.co.uk/news/health/cannabis-being-used-treat-symptoms-26110340

Author’s acknowledgments:

• Alex Fraser, always an excellent source of knowledge.
• Dr Daniel Haroon, for piquing my interest in this and so many other avenues.