Health Committee on Sept. 13th, 2017

[François Gagnon]

Different approaches are taken to different psychoactive substances. For alcohol, it is generally accepted that it is pleasurable to consume and the alcohol regulation framework seeks to reflect that.

For tobacco, it is not at all accepted that its use can be pleasurable or beneficial. Users can nonetheless say that they enjoy it in some way because otherwise they would not consume it. So the approach truly differs from one substance to another.

The pleasure and benefits that users enjoy from consuming a substance must be better reflected in policy development. That said, you are perfectly right in pointing out that there are different consumption patterns.

We have not mentioned today that, according to the best figures available to us, it is just a small percentage of users who consume a large part of the production. This is true for alcohol and tobacco. For cannabis, we do not have sufficient data in Quebec to clearly indicate this, but we suspect this to be the case.

In Colorado, for instance, about 20% of users account for 80% of all the cannabis consumed. Both the regulatory approach and prevention and treatment policies must therefore make these distinctions and tackle these issues head on.

[Don Davies, NDP, Vancouver Kingsway, BC]

You've said that quite well. I guess that's what I'm asking. None of them are perfect analogies. Cannabis isn't the same as alcohol. It's not the same as tobacco. I agree that tobacco gives a sense of pleasure, but I don't think there's a smoker who will tell you that it's good for them in any way. But I think cannabis users who use it occasionally and responsibly would probably differentiate that product. How do we differentiate, from a public policy point of view, responsible cannabis use?

[Marc Paris]

One caveat we have to make with cannabis is with regard to drug-impaired driving. In that particular case, as far as I'm concerned, impaired is impaired. We have to make it clear to everybody that whether you're smoking pot or drinking alcohol, or worse, the mix of the two, you shouldn't be driving a vehicle, end of story.

Beyond that, absolutely, we can't say that everybody who smokes a joint is going to be stoned out of their heads. The danger is if we don't have a controlled way in terms of the contents. When we get into highly concentrated marijuana, like shatter, which is essentially a concentrate that has up to 30% and even more of THC, this is getting into serious levels of psychoactive content. I have to believe that it starts to get into a danger zone. It's like having 80 proof alcohol.

[Dr. William J. Barakett]

People become non-functional when the levels of THC are so elevated.

I like the way you put it: legalize, regulate, and discourage, but if we're going to legalize, that means you have to regulate, but who are we discouraging? Is it youth? Also, we are educating adults about the use. As I said, a lot of people are self-medicating, whether it's for a painful condition or a psychological condition.

The other thing is, with the legalization is going to come the availability of oral compounds that they can take. Why should people be smoking this stuff and taking in all the products of combustion?

There's a big field ahead, and I think the government is dead right in proceeding with legalization because of the fact that it gives us an opportunity to educate.

[The Chair, Liberal, Bill Casey]

Mr. Oliver.

[John Oliver, Liberal, Oakville, ON]

Thank you very much. When we heard from Colorado, we actually saw a letter they had drafted that had gone to the attorney general, the honourable Mr. Sessions. It said that in the most recent national survey on drug use and health that between 2013-14 and 2015-16, the period in which adult-use marijuana businesses really opened their doors, youth marijuana use had declined by about 12%. They attributed that quite remarkable outcome—because we haven't achieved that—to three different activities. One was enhanced funding for law enforcement to really tackle the black market and make sure there were proper restrictions put in place and charges being laid, which the government has currently done. Appropriate education and awareness was another one. In fact, they had appropriated $22 million, I think, from their marijuana tax revenues for education, which goes right to the heart of what I think your message is, Mr. Barakett and Mr. Paris. That's really what you're here to talk about. The third was strict regulatory provisions to prevent youth use, including age verification requirements, point-of-sale requirements, and prohibitions on advertising, packaging, and products. When I asked them if in those three tiers of activities there was a magic bullet, they said they were all really important to getting that youth utilization rate dropping.

I know you're here primarily to talk about the importance of education and the health promotion message. The other two you're simpatico with as well. Do you have any concerns about these other two?

[Marc Paris]

I totally agree. I think regulation has to be important. How is it going to be sold? Where is it going to be sold? What are the contents? What about edibles? Where is it going to be consumed, publicly or in the house? Are we going to allow parents to smoke pot in their cars when their kids are sitting in the back? These are very serious questions. If parents have four cannabis plants in the back yard, what if the kid goes in the back yard and starts chomping on leaves? There are lots of scary scenarios.

[John Oliver, Liberal, Oakville, ON]

I think the act and the government's actions find a really good balance in those priorities, and I think you're really emphasizing that education message.

[Marc Paris]

The parents have to take the responsibility.

[John Oliver, Liberal, Oakville, ON]

I have one other question. It's on your non-profit model, which is an interesting model. It's the first time I've heard that one being put forward so strongly. In Colorado, they raised a concern about preventing vertical integration in the industry, in particular, separating grower-producers from distribution-marketing, from retail. In a non-profit model, would you have concerns about vertical integration? Do you think they should be separated, that there should be three categories of non-profits, or do you think a monopoly vertically integrated non-profit would work?

[François Gagnon]

The model we proposed to officials in Quebec included a state monopoly, which prevents vertical integration of the market. Whether it is a completely public system, a private system, or a distribution system was less important to us than the type of model. In any case, the model we have proposed prevents vertical integration of the market.

[John Oliver, Liberal, Oakville, ON]

I guess that makes sense. In a non-profit environment you're not worried about a monopoly to that extent then.

Those are my questions. Thank you.

[The Chair, Liberal, Bill Casey]

I want to thank the panel on behalf of our committee. We've certainly learned a lot, and we've enjoyed your presentations, your comments and information.

There's a lot of consistency within the hearings and the presentations we're getting. There's been a lot about research, information, public awareness, and training.

Again, I want to thank you on behalf of the committee for taking the time to do this and for sharing your experience.

We're going to suspend and return at four o'clock.

[The Chair, Liberal, Bill Casey]

I'll call our meeting number 66 back to order.

Now we have a panel here to discuss prevention, treatment, and low-risk use of cannabis. We welcome our visitors by video conference and those who are present.

I'll go through an introduction.

As an individual we have Gabor Maté, retired physician, by video conference from British Columbia.

Then we have, from the Centre for Addiction and Mental Health, Benedikt Fischer, senior scientist, Institute for Mental Health Policy Research. Hopefully we also have Bernard Le Foll, medical head, addiction medicine service, by video conference from Toronto.

Do we have him?

I don't think we have him. We have an empty chair.

From the City of Toronto we have Eileen de Villa, medical officer of health, Toronto Public Health.

Thanks very much for coming.

As an individual we have Sharon Levy, director, adolescent substance abuse program, Boston Children's Hospital, by video conference from New York.

Welcome. Thanks for taking the time to help us with this.

From the Ontario Public Health Association we have Michelle Suarly, chair of the cannabis task group, and Elena Hasheminejad, a member of the cannabis task group.

Welcome, and thanks very much.

We're going to open with 10-minute opening statements. I understand that some of you are splitting your time, but we'd like to try to keep it to 10 minutes.

I'm going to offer Dr. Maté, retired physician, to open up with a 10-minute opening statement.

If you would like to, give us an idea where you stand.

[Dr. Gabor Maté, Retired Physician, As an Individual]

Thank you for including me in this conversation. It's a pleasure to be here.

I worked for 12 years in the Downtown Eastside of Vancouver, which I think is notorious throughout North America as the continent's most concentrated area of drug use; and right now I travel extensively internationally to speak on addiction and related issues.

In terms of cannabis, first of all, I welcome the legislation that's going to bring some rationality to the policy around this substance. Drug laws in general—and I'll refer to that later—are quite irrational, in the sense that they have no connection to logic and very little connection to science whatsoever.

When it comes to marijuana, it's a substance that's been around for a long time. I think the first archaeological evidence of its use by human beings goes back 4,000 years, and it was first mentioned in a medical compendium published in China in 2,700 BC, so that's how long its use goes back.

In modern times, it was well known to the British in India, where physicians studied it and found it to be helpful in tempering nausea, relaxing muscles, and treating pain. As a matter of fact, Queen Victoria herself was prescribed marijuana for menstrual cramps, so the medical use of the substance and what you might call its recreational use go back a long time.

In terms of its addictive potential, it's just a misbelief that the plant is either in itself addictive or that it's a gateway plant for other addictions. If there's a gateway substance to addiction, it's tobacco, because most people who end up addicted to anything have used tobacco first. But it's not a question of gateways. The fact about any substance, whether it's marijuana, heroin, alcohol, food, or stimulants like cocaine, is that most people who try it even repeatedly never get addicted, but a minority will.

The question always becomes whether the substance is addictive. The answer is yes or no. In itself, nothing is addictive, and yet potentially everything is addictive. Whether something becomes addictive or not depends very much on the individual susceptibility. Now those susceptibilities may be to some extent genetically determined, but for the most part I don't think that's where the answer lies. I think fundamentally that substances that people use serve a function in their lives.

If you take the case of ADHD, for example, it's well known that kids with attention deficit hyperactivity disorder are more likely to use marijuana. Why? Because it calms the hyperactive brain. Very often addictions are self-medications; they begin as self-medications.

Marijuana also soothes anxiety. Now does that mean therefore it's benign? Not necessarily, because some people will start to self-medicate and they start using it to the point that now it creates a problem in their lives. Now it's an addiction. So the question of a substance being addictive is not to do with the substance itself, but whether or not a person uses it to the degree that creates a negative impact on their lives. Like any other substance, marijuana can do that, so it's neither true that it's addictive, nor is it true that it's not addictive. Again, it's a very individual matter, and the question is how we approach that.

First of all, we have to approach it rationally. This may be shocking or surprising to non-medical personnel, but legal substances like tobacco and alcohol are medically far more harmful than almost any of the illegal substances. For example, if you take 1,000 people who are heavy smokers or heavy drinkers and compare them to 1,000 people who use heroin in a non-overdose amount every day, and you look at those people 10, 15, or 20 years later, you will see that there's going to be much more disease and death in the alcohol and tobacco users than amongst the heroin users. This is especially true for marijuana.

Long-term studies show that over time marijuana users just don't suffer significant consequences, with one significant exception, and I hope the committee takes this into account, which is that there's a very persuasive study out of Britain that showed that if adolescents use marijuana extensively during the period of brain development, that can actually have deleterious effects on their long-term psychosocial and cognitive functioning. In other words, while it's true that marijuana is not as harmful as the already-legal substances of tobacco and alcohol, it's also true that if it's used extensively during the stage of brain development in adolescents, it can have negative long-term effects.

The question is how to address these problems. The trouble with adolescents and marijuana is that even when the substance has been completely illegal, as it has been up until now, it has not stopped adolescents from using it. In fact, it's the easiest thing to get for almost anybody aged 12 onward.

I don't know what, in the legislation, can possibly address that issue. I don't know what legal measures can stop the use by adolescents. In other words, when we're looking at prevention, we really have to look at why people use a substance, what's in the culture that's driving their use, and how we can address those issues.

Unfortunately, when it comes to drug prevention strategies, the idea of telling kids that stuff is bad for them just doesn't work. The reason it doesn't work is that the kids who will listen to adults are not at risk; the kids who are really at risk are not listening to adults. The real issue is how do we create conditions in our homes and our schools so that children will actually listen to what adults tell them. Without that connection, that trust on the part of the adolescent, they will simply listen to their peer group far more closely than to adults.

There is such a thing as marijuana addiction, and I'll define addiction as any behaviour, substance related or not, that a person craves doing, finds temporary pleasure in, or enjoys, and finds relief temporarily from, but which causes negative consequences in the long term and the person can't give it up. That is what an addiction is.

When it comes to treating any addiction, simply trying to address the addiction itself is inadequate, because there's always a reason why people use a substance or engage in a certain behaviour. When you ask somebody why they use marijuana, they'll say it makes them more relaxed. When you ask somebody why they use heroin, they'll say because they won't feel emotional pain.

In other words, the real problem is not the use of the marijuana or the heroin, the real problem is the emotional pain that person feels. The real problem is the overwhelmed state of their brain. In other words, the addictions are always a secondary attempt to solve a problem. Addiction treatments in this country, I have to say, for the most part don't address the real issues. Addiction treatments, for the most part, address the behaviour of addiction but not the underlying causes of it—not the underlying purposes that the individual finds in their behaviour. Those treatments will be insufficient.

When it comes to prevention, I think we have to look at what conditions in this society promote substance use in large numbers. If we look at the statistics for children, the number of kids who are anxious and depressed, alienated, troubled, or diagnosed with this, that, or the other thing is going up and up all the time. Every year the statistics are more and more dire. That's the real issue.

The drug use is a secondary phenomenon. It's those primary issues in our society that are driving the mental discomfort of our youth that we have to address. Those are broad social questions.

When it comes to treatment, again it's a question of how do we address the trauma, stress, and emotional distress of individuals who then use substances to soothe those factors. Again, we have to look into causes rather than just behaviours. I don't know where I stand in my 10 minutes. I'd like to bring it to a close.

I'm going to say that I'm encouraged by Parliament's willingness to take a rational perspective towards something about which our attitude has been completely unscientific and irrational. I just hope that the same open-mindedness and willingness to be realistic will soon be extended to drug policy in general, because all the irrationality that has characterized marijuana policy in this country for decades still characterizes opioid policy, for example. The current epidemic of opioid overdoses could be addressed effectively, but only if we take science and experience into account and only if we actually look at the evidence.

Some years ago I was asked to speak to a Senate committee on an omnibus crime bill and I said to the honourable senators that as a physician I'm expected to practise evidence-based medicine, and that's a good thing. When it comes to drug laws, I wish Parliament would practise evidence-based politics, because the evidence internationally is that the current approaches to drug use normally do not work. They make the problem worse.

Thank you for your attention. I'm very encouraged to see this moving forward and I hope there will be more to follow.

[The Chair, Liberal, Bill Casey]

Thank you. On behalf of the committee we very much appreciate your taking the time to do this.

Now we're going to go to the Centre for Addiction and Mental Health. We have Dr. Fischer, and I understand you're going to split your 10 minutes with Dr. Le Foll. Is that correct?

[Dr. Benedikt Fischer, Senior Scientist, Institute for Mental Health Policy Research, Centre for Addiction and Mental Health]

Yes, and I'm very glad that he's actually here now.

[The Chair, Liberal, Bill Casey]

Oh, there he is. The chair is full.

[Dr. Benedikt Fischer]

Thank you, honourable members. It's great to be here and to share some thoughts with you.

My name is Benedikt Fischer. I'm a senior scientist at the Institute for Mental Health Policy Research at CAMH, and chair in addiction psychiatry of the Department of Psychiatry at the University of Toronto.

I will share my opening remarks with my colleague, Dr. Le Foll. I will speak to you primarily from the public health perspective, and he will speak primarily from the clinical perspective on treatment.

I have worked on cannabis epidemiology, interventions, and policy for almost 20 years. Let us generally say that we very much welcome the federal government's initiative towards legalization of cannabis use and supply with strict regulations, because we believe—and we have stated this clearly in our 2014 CAMH policy framework—that this is the best way to improve public health and the safety outcomes related to cannabis use. We have said that before it was politically popular on the federal level.

On cannabis use, I'll make a few substantive comments. Cannabis use is not benign in terms of health risks. Cannabis use is associated with a number of different acute and chronic health risks. I will not repeat those; they're very well documented in the scientific literature.

This is a panel on prevention and treatment interventions. I'll elaborate a bit on the prevention side. In the intervention field, we typically distinguish between primary and secondary prevention, primary prevention being general prevention, and secondary or targeted prevention being aimed at users to reduce concrete use-related risks for adverse outcomes.

Let me emphasize that primary prevention for cannabis, especially under legalization, is an important facet of policy and interventions. Let me emphasize that abstinence from cannabis use is still the safest and most reliable way to avoid and reduce the risks of use.

However, we have a large number of Canadians—about 15% of the adult population, but up to 40% to 45% of youth and young adults—who've made the decision, for whatever reasons, to be users. So we have to combine our efforts on the prevention side both to keep the true abstinence rate as low as reasonably possible and to do everything we can to reduce the risks and harms among those large populations of people who've made the decision to actually use. That really, in essence, is the main practical challenge under legalization.

Given that the majority of use is concentrated in the 15-to-29 age group—in other words, youth and young adults—we have to ensure that this sizable population of young Canadians makes it through that cannabis use period into mid- and late adulthood with as little and the most limited health and social harms as possible for legalization to succeed as a public health intervention. That's essentially the quintessential challenge under legalization policy for the benefit of public health.

To elaborate a bit on the secondary or targeted prevention side with some examples, secondary prevention is of course a very broad realm or range of efforts that relate to a lot of different details of how legalization is designed and implemented. In other words, these are things such as what do we sell, where do we sell, who do we sell to, and how do we control distribution, but they're also things like avoiding the promotion and advertising of cannabis, and also pricing policy. All those kinds of aspects of the organization of legalization as it is enacted, as we know very well from data from alcohol and tobacco policy, are extremely powerful levers in terms of the risks and harms that we want to avoid. A lot of these details—or the devil that is in those details—are very relevant to the kinds of outcomes that legalization policy will produce and entail.

I'll just give a couple of examples. What will be extremely relevant for those kinds of risks and harms is what products are sold. We should avoid selling high-risk and high-potency products. At the same time, things such as edibles should be allowed, because they bear the potential to reduce, for example, smoking-related harms.

We should categorically not allow any kind of commercialization through advertising or promotion that leads to higher use and higher harms. As we know from alcohol and tobacco, we should keep distribution in public monopoly hands.

Pricing and taxation is enormously important, but not in a static way. It needs to be flexible so that we can adjust to organize demand and supply.

I'm personally concerned about restricting cannabis use—and potentially production through home growing—to private homes. It's not in the good interest of public health.

Finally, there's also the potential to reduce risks and harms among cannabis users through behavioural choices they make. That's exactly the conceptual basis of the lower-risk cannabis use guidelines that we launched in June from an international committee of scientists, published in the American Journal of Public Health and endorsed by the federal Minister of Health and five leading national health organizations. This is one ready tool for targeted prevention among users, as part of a comprehensive prevention strategy that we're happy to help with.

I'll hand it over to my colleague, Dr. Le Foll, to speak on issues of cannabis disorder and treatment.

[Dr. Bernard Le Foll, Medical Head, Addiction Medicine Service, Acute Care Program, Centre for Addiction and Mental Health]

Thank you, Benedikt.

Honourable members, thanks for the opportunity to talk about the treatment of cannabis use disorder. By way of introduction, I am a clinician scientist working at the Centre for Addiction and Mental Health. I practise addiction medicine. I have done research on the impact of cannabis, doing studies on cannabis administration in human subjects as well as clinical trials studying a treatment approach for cannabis use disorder.

I would like to start by describing a variety of clinical presentations we can see. We can have subjects presenting with cannabis intoxication. The symptom may be euphoria, but it can be also tachycardia, impaired judgment, and psychiatric complications associated with intoxication. I'm talking here primarily of physiological symptoms and psychosis symptoms.

There is no overdose associated with cannabis, so it's much less risky than opioids, which can lead to death.

There are also a clear symptoms that can occur when a subject discontinues exposure to cannabis after regular prolonged use. There is a typical cannabis withdrawal syndrome. It presents with anxiety, dysphoria, sleep disturbance, irritability, anorexia. Cannabis withdrawal can be distressing, but it's not life threatening. Even so, we know that withdrawal symptoms make cannabis cessation more challenging and that these symptoms are associated with a higher risk of relapse.

The main challenge is the loss of control over the use of cannabis. This can develop in a fraction of users and can result in an addiction problem. Currently in the field, we are defining this as cannabis use disorder. Cannabis use disorder is characterized by a pattern of cannabis use that causes clinically significant distress or social impairment resulting in negative consequences such as the inability to stop using.

Previously the field was using the terminology of “abuse” and “dependence”, with dependence being the most serious form of addiction. The research based on epidemiological surveys clearly indicates that 7% to 9% of those who use cannabis during their lifetime will develop a dependence at some point in their lives. There is a fraction of people who will lose control of their use and will develop cannabis use disorder. It is estimated that the fraction is 30% to 40%.

It is important to realize that those numbers are lifetime numbers, which means that you have subjects who will experience problematic cannabis use only for a restricted period of time in their lives and who will get over this kind of problematic use without necessarily requiring specialized treatment. This is currently seen as a growing problem, however, because we see more and more people coming to addiction treatment who require treatment for cannabis use disorder or who have addictions associated with cannabis.

I would like to make it clear that at this point the number of subjects coming for addiction treatment with cannabis use disorder as the main reason is very small compared with the number of subjects who seek treatment for alcohol or opioid addiction.

Treatment of cannabis use disorder can be performed in an out-patient setting, but sometimes patients can be treated as in-patients or in a residential setting, but usually that is more for the subjects who have concurrent psychiatric or polysubstance use. It is recommended that the treatment provider evaluate precisely the treatment goals of the patient and understand that these goals may vary greatly. Some subjects may want to be completely abstinent; others may want to reduce their level of use or avoid risky use.

[The Chair, Liberal, Bill Casey]

Dr. Le Foll, I'm sorry, but your time is up. Could you bring it to a close?

[Dr. Bernard Le Foll]

Sure.

At this point in time, we have interventions that are effective. They are psychosocial interventions, mostly cognitive behavioural therapy and motivational enhancement therapy. The analysis of the literature indicates that those are the most effective treatment approaches. It should be noted that the treatment sector in addiction is not necessarily using those approaches that have shown the best efficacy. There is currently research being done on pharmaceutical treatment for cannabis use disorder. This is not yet a mainstream treatment approach. It's still under the domain of research, so we do not currently have pharmacological interventions available. We think that it's very important that more trials be done in this area to generate the evidence that we need to better practise in the future.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Now we'll go to the City of Toronto.

Ms. de Villa.

[Dr. Eileen de Villa, Medical Officer of Health, Toronto Public Health, City of Toronto]

Thank you.

Good afternoon, everybody.

[The Chair, Liberal, Bill Casey]

I'm sorry, Dr. de Villa.