Public Accounts Committee on June 9th, 2016

[TJ Harvey, Liberal, Tobique—Mactaquac, NB]

I want to follow up on my colleague's comments about the 10 grams a day. I have a good friend who is paraplegic, and he takes medical marijuana for that exact use. In New Brunswick, until recently the musculoskeletal rate was 1.5 grams to 2.5 grams per day. It was increased in the last year to 3 grams per day, which is actually at the high end of the average doses. If you go to the Health Canada website and look at the recommendations on there, it says:

For smoking and vaporizing, the median reported dose was 1.5-2.0 grams per day respectively. For edibles, the median reported dose was 1.5 grams per day. For teas, the median reported dose was 1.5 grams per day.

It's your department, and basically Veterans Affairs has identified that the need of a veteran is more than four times the amount of an average Canadian.

I'm not done yet, but when I'm done, you're more than welcome to speak.

I also know that the cost for medical marijuana is, at the low end, $6 on average, and at the high end it's $10. So it's an average of $8. I do understand there are strains that cost upwards of $20, but that's at the very high end, and it's for a very concentrated product.

If you have a veteran who is using 10 grams per day, which is more than 4 times the amount of the average user, at the high end of the dosage levels, to me, something in that just does not compute. Also, if you figure it out by average daily usage, in the medical marijuana study that was done of current medical usage across the country, the average usage was identified at around 90 grams per month total usage. For a veteran who is taking 10 grams per day, that would amount to over 300 grams per month. At an average cost of $10 a gram, that's $30,000 a year.

I question whether all of that usage is actually being done by the veteran. Maybe that's not a conversation that anybody wants to have, but I'm lobbing the question out here because it's right there.

I have a second question. What is the specific budgeted amount for medical marijuana forecast for 2016-17 and 2017-18?

I do believe those numbers should be available somewhere because Veterans Affairs' report on plans and priorities for 2016-17 does include budgetary numbers, so obviously there is a budgeted number.

[The Chair, Conservative, Kevin Sorenson]

Mr. Natynczyk.

[Gen Walter Natynczyk]

I would just like to say that your concerns are well founded. It's precisely because of all that you've just layed out that the minister has launched this review. You're exactly spot on with your points. That's why the minister wanted to make sure that we actually get the best evidence we can from across all of the realms, from the medical experts and the producers, going into the price points and the strains that you've mentioned, as well as the beneficiaries. Obviously, we cannot meet with all the beneficiaries, but with a select group, to understand the various perspectives as we try to figure out how to move beyond this guideline that was put in place in 2014, and how to normalize this to ensure that there is not an unintended consequence of making the health worse for the veterans, and indeed supporting the physicians for the well being of those veterans.

This is precisely why we're working on this. We've been working, and as I mentioned before, we just had a summit of all the veterans associations here in Ottawa recently, to educate the community in terms of the kinds of points you just mentioned.

I will just ask Michel Doiron and Dr. Courchesne if they could wade in. I don't have the numbers on me with regard to 16, 17, or 18.

Over to you, Michel.

[The Chair, Conservative, Kevin Sorenson]

Very quickly, please. Our time is pretty well up. I'll give you a little extra time.

[Michel Doiron]

If it's okay with the chair, I'll provide the exact numbers later. I have the numbers for the entire medication, but not for marijuana specifically. I can provide that to the committee after this meeting, if it's okay. I have the general number, but not the specifics.

As the deputy said, this is exactly why we're following up on the policy. We did put in place the limit of 10 grams, because once Health Canada changed, we were caught and we did cap the amount. We had started looking at what the optimal amount or right amount was. That is the work that we are doing in developing the policy, by talking to the experts, talking to other jurisdictions, and following up on the points you've raised. We were aware of those. These are all things that we have followed up on.

Even for the producers, what does an average Canadian take versus a veteran? They have different categories. I won't get into all of the details of who takes what, but some are at that level, some are a little higher, and some are over that.

We need to come up with a reasonable policy that will meet the needs of our veterans by ensuring their health, but also make sure that we're not causing a downstream effect with the marijuana.

[The Chair, Conservative, Kevin Sorenson]

Dr. Courchesne, did you have a comment on that?

[Dr. Cyd Courchesne]

With respect to the amount, we can't assume they're smoking the entire 10 grams every day. When we talk to the veterans, some put it in their smoothies, some make brownies with it, and some extract oil, which requires higher quantities. We can't assume that all of our clients are at the high end of the 10 grams.

[The Chair, Conservative, Kevin Sorenson]

Mr. Harvey is going to burst if I don't let him back in here.

[TJ Harvey, Liberal, Tobique—Mactaquac, NB]

The only reason I made the point is that it's right on the Health Canada website and that—

[Dr. Cyd Courchesne]

Yes, I have it right here.

That's what they report. They're not recommending, but they're reporting that—

[TJ Harvey, Liberal, Tobique—Mactaquac, NB]

What they're reporting is what their findings have been, and based on the evidence not only from here, but from a study that was based out of the Netherlands, that when marijuana is consumed in alternative forms besides inhalation, the amount that's consumed on a daily basis goes down.

To say that is a plausible reason why consumption levels could be so high is categorically false.

[The Chair, Conservative, Kevin Sorenson]

Thank you, Mr. Harvey. Maybe we'll have a chance to come back to you on this.

We'll go to Mr. Godin.

[Joël Godin, Conservative, Portneuf—Jacques-Cartier, QC]

Thank you, Mr. Chair.

I appreciate my colleague's question. It is very relevant.

I don't want to demolish what is being done currently, but I think we have created a monster. Before marijuana was legal, what did we do? Did our military people receive poorer treatment, and were they in worse shape? How is it that marijuana has become the cure-all of the century and that it is being prescribed across the board? The 2013-2014 budget was multiplied by 25 in two and a half years. What did we do before?

For the moment, my question is limited to that point. I have other questions, but what used to be done to treat people suffering from post-traumatic stress syndrome? Did they prescribe alcohol?

[Gen Walter Natynczyk]

Gentlemen, I confirm that marijuana is not only used for psychological problems, but also for physical injuries. Our information indicates that many military people with musculoskeletal injuries use a lot more marijuana than those who suffer from psychological issues.

We have found that modern physicians authorize it in the form of various medications. From time to time, our veterans really have trouble, especially those who have complex pains.

I'll ask if Cyd could add a bit there.

[Michel Doiron]

Before 2014, veterans had to go to Health Canada and provide their information to that department. They were reimbursed, but the reimbursement process was more complex. That does not mean however that veterans did not use it. It means that we did not reimburse them for the reasons mentioned by the deputy minister.

Since 2014, the rules have changed. Doctors may authorize the use of marijuana and we reimburse the incurred costs. Before that, the person had to obtain authorization from Health Canada, and they had some very strict criteria. A court—I believe it was the Supreme Court—ruled in favour of amending the regulations. That change brought about a marked 25% difference.

I am not ready to say that before that date, our veterans did not use marijuana. The process to obtain it was however far more controlled and it was not prescribed by a physician. Now, physicians provide the authorizations.

[Joël Godin, Conservative, Portneuf—Jacques-Cartier, QC]

In fact, measures were put in place to facilitate access to marijuana. As legislators, we see that the budget for marijuana reimbursement has exploded and we don't know how this is going to end. Over the last nine months of 2015, the amount spent on this was 25 times greater than what it was two years ago.

We have to put in place some limits and controls. In the past, the quantity was 10 grams a day, but we also heard that that may or may not have been consumed. We have to be more rigorous with this. Personally, as a legislator, I am very uncomfortable to be discussing the possibility of a constantly growing budget for this, without adequate controls.

What measures are you going to put in place to control and monitor this expenditure better? I am not saying that the treatment isn't effective, but I think that things are too free and too accessible. We are trivializing the use of marijuana. Any soldier coming back from a mission can be advised to consume marijuana by his fellow soldiers, who assure him that this is going to do him good. At a certain point, I think we have to be more responsible.

What do you intend to do to introduce stricter controls over all of this?

[Gen Walter Natynczyk]

Mr. Chair, as I mentioned previously, physicians have the authority regarding marijuana, and are responsible for the overall health, both physical and mental, of our veterans who return to civilian life. It is important that we insist on that point.

That said, Mr. Godin, you are entitled to be concerned. That is why we are currently reviewing the policy using all available information and recommendations made to our minister in this regard. After that, we are going to consult experts everywhere in Canada, and veterans who use marijuana.

[Michel Doiron]

We understand your concerns. As the deputy minister was saying, that is why we are currently working with experts and the medical community in order to develop a policy we will submit to Minister Hehr, so as to ensure that rules involving marijuana are much clearer and more precise, whether we are talking about quantity, costs or other aspects.

You must understand that there is a difference between marijuana and the other medications. Generally, when medications are prescribed, prior analyses have been done. There are protocols; if you have a sore throat, penicillin must be prescribed three times a day over five days, for instance. I am not a doctor, and my colleague could tell you more about that.

However, when it comes to marijuana, we still don't have expertise like that either in Canada or elsewhere. We do however note trends and situations where it seems that marijuana gives people relief.

[The Chair, Conservative, Kevin Sorenson]

Our time is up.

For those who may be watching this, we've heard part of the concern. In fact, in the deputy minister's opening statement, he showed the increases up to 2013. In 2013, $408,810 was budgeted for 112 recipients; in 2014, $5,160,747 was budgeted for 628 recipients; and in 2015, it was $12,156,000 for 1,320 recipients, with a forecast of that amount doubling again next year. That would be $25 million. When you go from $400,000 to $25 million over three years, if we don't ask questions about on that, people will be shaking their heads, I'm sure.

Mrs. Mendès.

[Alexandra Mendes, Liberal, Brossard—Saint-Lambert, QC]

I'd like to begin by saying that I'm perhaps going to seem the odd one out. I'd like to take away the value judgments and moral judgments that I'm hearing a lot of in regard to veterans' use of marijuana. I do not want to have our veterans seen as using this as a joyride, as some people are assuming. That is my first comment.

I want to ask about the costs and how we're using the budget for the authorization of marijuana use, not the prescriptions. Do you have any comparisons? You know how much you've spent on the marijuana. How much lower is it than for your other medications?

The deputy minister made a point of telling us that some veterans used the example of showing a full pack of medication they had stopped using once they started on marijuana.

[Gen Walter Natynczyk]

To the first part of your question, many of our veterans find marijuana for medical use to be beneficial to them. Again, it is very compelling, and the challenge is that it's very anecdotal. As Dr. Courchesne indicated, we don't have a medical research branch in Veterans Affairs, but with National Defence and Health Canada we partnered to create the the Canadian Institute for Military and Veteran Health Research. It's basically a system of systems of all of the medical schools across Canada with research branches in all of our universities who do research on both military and veteran health issues. It also links to our allies in the U.S., U.K., Australia, and the Netherlands so that we are aware of the best practices across the board. Dr. Courchesne is our link in that network of researchers, and this is clearly a significant body of research that challenges the evidence that, as has been mentioned, isn't there yet.

Yet, anecdotally, it is so compelling. When you meet our veterans, they will lay out all the bottles of various medications they no longer take because they are now able to take marijuana for medical use. They are able to sleep, they're able to eat, and they're able to undergo treatment at our operational stress injury clinics. They're able to undertake vocational rehab and education, whereas under all of these other various drugs whose names I can't pronounce, they were in a fog and could not function. We have that anecdotal information that, again, was an education to me, as it was to many in the department. Again, hearing from the medical experts from across the field, I think, is really important.

I think there was a media story about this recently, indicating that our spending on opioids and other pharmaceuticals had gone down, as has been mentioned, while that on marijuana for medical use has gone up significantly. While we recognize that those two numbers are correct, we do not have sufficient evidence to make a causal relationship.

[Alexandra Mendes, Liberal, Brossard—Saint-Lambert, QC]

Would it be possible to have it eventually?

[Gen Walter Natynczyk]

We are certainly looking at all of this information. I'll just ask my colleague—

[Alexandra Mendes, Liberal, Brossard—Saint-Lambert, QC]

I think it would be important, actually. It's part of the whole....

[Gen Walter Natynczyk]

Yes, I would ask my colleagues to chime in.

Michel.