Veterans Affairs Committee on Nov. 22nd, 2018

[Dr. Yanbo Zhang]

I think the most challenging part is that we do not have a unified voice. From different parties and different institutes and different interest groups, the information may come with very different attitudes.

As we know, from the Canadian Medical Association, the Canadian Psychiatric Association, and all the provinces, we've been making a lot of pamphlets and education materials to try to educate our members, based on what we know. However, that's not really helping the physician who prescribes marijuana. Why? Because when we do the education, the majority of physicians do not really prescribe...or authorize it, and it's because of the concerns about the side effects.

So the message delivery is there, but it's not really an efficient way to do that.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Thank you.

To go back to the anecdotal, I'm working on the case of a young man who is suicidal. Over the last five or six years, he was prescribed 29 different cocktails of medicine. There were frequent changes. He was in a state of anxiety, depression, and all the things that go with PTSD. He described his experience with marijuana as being the first time he'd had a good night's sleep in two years. His family called it a godsend.

How do we reconcile this? What is prescribed has to be safe, and I understand that. We don't want to injure anyone more than they are already injured, but when a veteran's wife tells me that her marriage is over because he's so anxious and they can't have any kind of life together and medical marijuana is the only thing that seems to help, how do we reconcile all of this?

[Dr. Yanbo Zhang]

I think this is the challenge of being a psychiatrist. Why? Because even though we have evidence for a lot of things, even for current medications, they might not necessarily work for individual patients. That's why we follow the guidelines made by a majority or a body of psychiatrists who have done enough research on it. We follow the first-line treatments and the second-line treatments, how we switch, how we add on different medications, and, if that's not working, what we do next.

When we face treatment-resistant depression or PTSD, we have to be innovative. We have to be adventurous. In that case, I'm not opposed to or against using CBD oil or using marijuana to help if we can relieve the pain or relieve the stress a patient has after we've tried everything. However, I strongly disagree with the jump to using marijuana as a first treatment without trying everything we already know, because that is dangerous. It will also lead to more troubles than those we're actually try to solve.

There's always a balance. There's always an exception. I do the same thing when we try a medication that has never really been used. It needs to be based on a full understanding between patients and physicians.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

It's interesting that there's been a lot of discussion about the use of medical marijuana. It's been there for quite some time. We know that. Why is there such a gap between the current research and tracking of therapeutic effects and the fact that, for quite a while, veterans and others have been using medical marijuana? Is it because people felt stigmatized in admitting that they were using marijuana?

[Dr. Yanbo Zhang]

I think Dr. Busse can probably answer this as well.

Very briefly, I'm thinking that it's because marijuana has only recently been legalized. In the past, the majority of research came from the FDA. They have really strict guidelines. All of the marijuana they use comes from one source. That source of marijuana probably comes from the 1960s in terms of the strains or in terms of the content. That's why a lot of the research....

It's also very difficult to get grants to support marijuana. The majority will be against it. If you look at side effects or substance abuse, you get grants more easily. That's why even the research itself is biased.

[The Chair, Liberal, Neil Ellis]

Mr. Bratina, you have six minutes.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

Thank you.

We have an excellent panel. I'm sorry about the shortage of time, because you're all offering us wonderful testimony.

I looked everybody up and you all have great qualifications.

Dr. Zhang, you studied medicine in China. I was in Qingdao with a medical delegation—

[Dr. Yanbo Zhang]

Wow.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

—and saw how traditional and herbal medicines are incorporated into the general practice. Cannabis exists in the Chinese experience. Are there any conclusions we can draw from that?

[Dr. Yanbo Zhang]

I don't think so. Why that is, is because ancient-time cannabis was totally different. As I just mentioned, in the 1960s cannabis was different. The hippies who did this drug could not necessarily do the same thing here. Also, since the Chinese government took over 50 or 60 years ago, all of the substances have been strictly banned. Now, it's a very strict penalty, so that's why there's almost zero research and zero exposure to marijuana. It's very difficult to get that.

The second one is, even for Chinese traditional medicine, the standard is different from the western medicine here. I do not think they're practising advanced medicine either.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

I see.

Dr. Busse, the testimony that Mr. Cohen gave is slightly at odds, and no disrespect, it's great to have this conversation. Mr. Cohen talked about Boone Cutler's story, which you heard. How would a pure researcher evaluate that kind of evidence? What would you do with it? It's obviously so powerful that Mr. Cutler has taken the steps that he has.

What would you say about that kind of story?

[Dr. Jason Busse]

I think we need to listen to those types of anecdotes. Anecdotes are a form of evidence and if someone has a dramatic improvement where they were completely non-functioning and with the addition of one particular treatment they then resumed employment, became functional and their symptoms regressed dramatically, that's a very important piece of information to work with.

As a researcher, if I was going to test that on an individual, I would embark on something called an n-of-1 trial, which is really a randomized controlled trial done at the level of the individual. I would randomize the intervention between the active cannabis and a placebo in a random order and I would see if the resolution of symptoms tracked according to what they were getting. There is a way to do studies at the level of the individual. I do take Dr. Zhang's point that a lot of the research we have talks about average effects. Even if something isn't working for the average person, there may be benefit for select individuals. What we then want to learn is what features distinguish the individuals who are more likely to receive the benefit, and what features distinguish an individual who is more likely to experience harm, or even to become addicted, so that we can make clinical decisions that are more responsible to those characteristics.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

Mr. Cohen, do you have any comments?

[Jacob Cohen]

Yes. I'd just like to add something, although it's anecdotal, on another huge issue with researchers. For example, Raphael Mechoulam, who discovered many of the compounds in the cannabis plant, for many years was actually conducting his research illegally and was obtaining his cannabis products from the Israeli police, who he somehow made a deal with.

The biggest problem is that cannabis and proper research, or actual tracking, is lacking. That's why we are where we are today and we have nothing other than anecdotal evidence, even though it's a weak point to go from.

But there are these almost miracle stories of these patients who are helped by it.

[Bob Bratina, Liberal, Hamilton East—Stoney Creek, ON]

I'm fine, thank you.

[The Chair, Liberal, Neil Ellis]

We have time for two two-minute rounds.

We'll start with Mr. Eyolfson.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you, Mr. Chair.

Dr. Busse, I want to ask you a question in the very little time I have.

Just for background, I'm a physician. When I was training—we're going back 20 years now—one of the things we had in the formulary was nabilone. I assume you're familiar with that. It was kept in the formulary in pill form—a THC pill. It was used as an antiemetic and for neuropathic pain.

Has there been any research in that form? That's something that has been around and has been on medical formularies for decades now. Is there any research on that with some of the indications that medical marijuana is now being prescribed?

[Dr. Jason Busse]

Yes, there has been research on nabilone, which is a synthetic THC analogue. You heard Dr. Zhang mention before that it is a strong agonist, so it has very strong binding to the receptors, which is different from the natural form of THC you'll find in the plant, which is a weak agonist.

We do have clinical trials of nabilone for the indications that you've mentioned. There is moderate quality evidence of effectiveness, which is why it was approved. What we now need to understand is if there is a different therapeutic effect between the synthetic THC analogues versus the products you're finding more in the natural cannabis that's more readily available now.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Are you familiar with any patterns in the community?

My practice was emergency medicine, so we never prescribed any form of cannabinoid from my practice.

Are you familiar with any prescribing patterns of nabilone in the community, or is that something that's been more or less restricted to in-hospital use?

[Dr. Jason Busse]

It's more likely restricted to in-hospital use looking at nausea and vomiting associated with chemotherapy.

There is a lot more of the authorization for medicinal cannabis, which we are seeing, based on the increasing numbers that Health Canada is tracking.

Again, a few physicians are becoming quite active in this space as well.

[The Chair, Liberal, Neil Ellis]

Mr. McColeman, you have two minutes.

[Phil McColeman, Conservative, Brantford—Brant, ON]

Thank you, Chair.

Reading from our briefing notes as they relate to veterans—I just want your reaction to this—the most recent data available from the department is that $31 million was spent on cannabis in the first half of 2016-17. This is reimbursement to veterans. The most current data reported is that we've spent $63.7 million on medical marijuana in 2016-17, triple the amount of the year before.

If there is that much take up of medical marijuana in the veterans community.... I've experienced this personally in the special needs community. Some of them have Dravet, and I missed the testimony. In the Dravet community and such, to get a—at least in my area of the world, which is Ontario—medical marijuana prescription, you can do it by a doctor on Skype, largely. You never meet the doctor. It's by Skype. They call them Skype doctors. You're probably familiar with those.

Do you think there is enough understanding through the medical community to justify this kind of growth in the veterans community of the use of medical marijuana? I'm not making a judgment call here whether it's needed or not needed. These numbers are off the map, from what I can see.

[Dr. Yanbo Zhang]

I can only speculate what's going on.

I wonder if the legalization of recreational use and the decrease of our resistance in terms of using marijuana have influenced the physicians' opinion of using it. You can buy it anywhere, and it's not a prescription drug, then it must be safe, or safer. I think the threshold of ours to balance whether we should give it or not becomes less strict. That can probably partially explain why it's going on.

I don't think there is any evidence shown for the last two years to say that we have reasons to change this attitude. That's just my speculation.

[The Chair, Liberal, Neil Ellis]

That ends our meeting.

Witnesses, on behalf of everybody here, I'd like to thank you for testifying and for all you do to help the men and women who have served.

The meeting is adjourned.