Evidence of meeting #100 for Veterans Affairs in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was research.
A recording is available from Parliament.
Liberal
Karen Ludwig Liberal New Brunswick Southwest, NB
Is there a common repository that we can feed the numbers into in order to start collecting them?
Homeless Veterans Representative, Dominion Command, Royal Canadian Legion
I can send you a copy of the stats we keep. That's not a problem. We're the only province that we know of...or the only command that we know of. I can tell you that as of this coming Saturday, that's going to change. We're going to get everybody involved so that we can get it together.
We started keeping stats from day one. I was one of the first people on the committee at Ontario Command to start the program. That's where I'm getting all the numbers.
Liberal
Karen Ludwig Liberal New Brunswick Southwest, NB
From your experience, do you see more supports or fewer for veterans than five years ago?
Chair and Co-founder, VETS Canada
There's definitely more. In some cases, there are too many supports. As I said in my testimony, it has become a very crowded landscape. It seems to be the issue of the day, so to speak. People are coming out of the woodwork trying to offer support. The key is this: Is there actually a service there? It's the credibility.
Liberal
Karen Ludwig Liberal New Brunswick Southwest, NB
What about conflicts? Is there a common conflict, such as a war conflict that the veterans have participated in, or is it just all veterans, from 17 to 92, as you mentioned, Mr. Gordon?
Director, Veterans Services, Dominion Command, Royal Canadian Legion
Yes. A veteran is a veteran is a veteran. I say that and we're honest about that, because there is so much out there where people do not come forward to submit a disability application because somewhere along the line someone told them that for the service they were in there's not an entitlement to apply. It takes a lot of effort to go back. I have a lot of World War II veterans who didn't serve overseas who were told that they couldn't put in a claim. Trying to talk them into submitting a claim at this time in their life when they want to stay at home and get VIP so they don't have to move into long-term care is challenging.
You talked about how there have been changes. Yes, there have been a lot of great changes, but you have to get the veterans in the door. You have to get them in the door to get them the service they need. Once they're in, you can get through the system, and it's pretty good, but you have to get them in.
Liberal
Karen Ludwig Liberal New Brunswick Southwest, NB
Do you also hear from veterans a concern about reporting a medical condition or a mental health condition to the military doctor while they're in service? I've heard from some who suggest that it can be career limiting.
Director, Veterans Services, Dominion Command, Royal Canadian Legion
Well, for folks who are still serving, we don't need medical questionnaires completed, and VAC doesn't require that for a disability application. It has to be in your service health records. For everyone who was in when we're doing a disability claim that is already diagnosed, those are new. You're talking about people who don't want to come forward because, again, it's a stigma issue. I'm not going to say that it has been eradicated, but we're seeing more people coming forward now than ever before, and the favourable rate on mental health claims right now has to be pretty close to 90%.
They've even changed philosophies there on how they're adjudicating claims. No longer are they giving just a 10% minimum on most. If they can give a definitive adjudication entitlement and an assessment at that time so that they don't need to have that person with a mental health condition come back a year or six months later, because that is a problem as well.... People just want to get in, get the treatment and of course get their disability awarded as well.
Conservative
Cathay Wagantall Conservative Yorkton—Melville, SK
Thank you, Chair, and thank you so much, Mr. Gordon, Mr. McInnis and Deb Lowther, for being here today.
I'm going to quote something from another individual who was testifying. Mr. Robert Tomljenovic, area director, Department of Veterans Affairs, was explaining, similar to what you're saying, that veterans, “like the general population, become homeless as a result of complex and interrelated issues such as health status, personal problems, employment instability, poverty, lack of affordable housing, addiction issues and others.” In addition, they have also experienced traumatic scenarios.
I can't help but think that homelessness and all of these things that are mentioned are symptoms of a traumatic experience. Whether you're a veteran or not, something has caused you to go down these paths that make life less positive.
Ms. Lowther, your program, Boots on the Ground, says to me that the majority of people with these traumatic experiences in our armed forces are the people who are the boots on the ground, the ones who face the fire, the explosions and all these kinds of issues. I'm so thankful for what you guys do, all of you, in what is really a crisis management scenario. I'm sure you would love to see circumstances change so that there is no homelessness. That's the ideal. I understand that it's not possible, but we could get much closer to it than we are.
Mr. McInnis, I believe you mentioned something around the issue of their needing to be fit to be transitioned. Our goal here has been to help create this seamless transition from National Defence through VAC to a healthy life as a civilian. Would you say that this area.... I know that VAC is not anxious to allow National Defence to be the ones to determine when you leave—and if you leave with an injury, whether it's service-related or not—in order to not have to go through that whole system again in going through VAC.
You were talking about needing more case managers. Can you talk a bit about that? If those circumstances were different, would those symptoms that our veterans face be different, the ones who are truly injured and struggle with these issues, with PTSD and whatnot?
Director, Veterans Services, Dominion Command, Royal Canadian Legion
Yes, it's very important, but I don't like the term “seamless transition”. There's nothing seamless about it. “Smooth transition” would be a better term to use—
Director, Veterans Services, Dominion Command, Royal Canadian Legion
—because even the people who are not injured when they leave the military still have a difficult time with transition to the civilian world.
Not to take away from all the civilians in the room, but the health care system is not as nice as it was when we served in the military. In the military, we were taken care of. You go in one door in the morning and you come out in the afternoon and everything was taken care of for you. You didn't know what you had—it was that good.
To me, transition is extremely key. If the Canadian Forces are going to have a mandate to keep you in longer to ensure that when you do transition over you're handed off and in a better state of mind mentally, physically and financially, then yes, a lot of problems will go away.
Conservative
Cathay Wagantall Conservative Yorkton—Melville, SK
If we're going to talk dollars, do you think if we invested more in maintaining their salaries until all of these things were dealt with further down the road we would actually, in the long run, end up spending less and having healthier citizens?
I'd like a quick yes or no because I have lots of questions.
Director, Veterans Services, Dominion Command, Royal Canadian Legion
That's a yes from me, as long as they're in the military and they're in this. That's why they are going for the additional positions because then they're going to be paid, and that's what the transition groups are supposed to be for.
Conservative
Cathay Wagantall Conservative Yorkton—Melville, SK
Okay. Thank you.
Ms. Lowther, I've been to the new drop-in centre. It is phenomenal, very exciting. I had the opportunity to meet Gary Davis in Victoria last week. Your services, as well as the Legion's, are very commendable. Thank you for what you're doing.
I know that in your first two months with the centre here you received over 60 referrals from case managers, in fact, to deal with emergency circumstances. What were their explanations for sending them to you?
With the emergency fund, what is the most effective way to use those dollars when we're dealing with veterans in emergency circumstances, through VAC or through veterans who are assisting veterans?
Chair and Co-founder, VETS Canada
Honestly, when the emergency fund was announced, we had several case managers who told us they don't want to be responsible for administering this fund. They would rather see the department give the money to VETS Canada and let VETS Canada do it.
What are the scenarios in which case managers are referring veterans to us or to our drop-in centre? They're varied, but one common theme is that we have the ability to provide immediate support.
To be very clear, the front-line staff at Veterans Affairs Canada are kind, caring people, and they are doing a wonderful job with the ability they have. They do deal with legislation and very restrictive policies and procedures, whereas we have the ability to be an outside-the-box organization. We don't have to have somebody sign off on a briefing note to expend some money, so we have the ability to be more responsive quickly.
Case managers know that, so I think....
Conservative
Cathay Wagantall Conservative Yorkton—Melville, SK
Thank you. Yes.
It's clear that you are doing a good job, Mr. Gordon, in regard to the database and information, something, quite honestly, we find there is not enough of, which I don't understand.
If you are doing that, do you see that it would be advantageous for groups that are succeeding in serving veterans if you share that information? You said there are really too many. Is Ms. Lowther aware of which ones you are serving in certain areas and whether there is overlap?
My husband was in the ministry and there were many times when people would come who truly needed help, but if you communicated throughout the area you would know that they had been to multiple areas and had not necessarily taken advantage of the assistance needed.
Do you see that database needing to be more comprehensive?
Homeless Veterans Representative, Dominion Command, Royal Canadian Legion
That's a good question.
We support and work with all the other organizations—VETS Canada. We've assisted them, and with department kits, and help if they come to us. Any organization that comes to us and has a homeless veteran who needs help, we're there.
Conservative
Cathay Wagantall Conservative Yorkton—Melville, SK
Do you both know who you are serving?
Are you serving the same people? I guess that's what I'm asking.
Director, Veterans Services, Dominion Command, Royal Canadian Legion
We're not double-dipping.
Liberal
The Chair Liberal Neil Ellis
Okay. Thank you.
Sorry, that ends the panel today. I know that hour went very quickly.
On behalf of the committee, I'd like to thank all three of you very much for appearing today, and for all you do for the men and women who serve.
We will recess to clear the room. We'll start momentarily with our other panel.
Liberal
The Chair Liberal Neil Ellis
Order, please. Could everyone take their seats.
This is the study on medical cannabis.
We're pleased to welcome, by video conference from Hamilton, Dr. Jason Busse, associate professor and associate director of the Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University.
With us in Ottawa we have Dr. Zhang, assistant professor, psychiatry department, University of Saskatchewan; and Mr. Cohen, master of science student and combat veteran, department of pharmacology and psychiatry, University of Saskatchewan.
We'll start with 10 minutes from each of you for opening statements, and we'll start with the video conference with Dr. Busse.
Dr. Jason Busse Associate Professor, McMaster University, As an Individual
Thank you very much. Good afternoon, honourable members of Parliament. I appreciate the opportunity to address the House of Commons Standing Committee on Veterans Affairs.
As noted, I'm an associate professor in the department of anaesthesia here at McMaster as well as the associate director in our cannabis research institute.
The cannabis research institute here is funded by philanthropic donation. We receive no industry funding, and our mission is to develop an evidenced-based understanding of cannabis, both in terms of its potential therapeutic benefits and also its associated harms.
Our centre's activities broadly include the synthesis and dissemination of current best evidence, the conduct and support of innovative research in areas where evidence is lacking, and the creation of a research network including both faculty members at McMaster and external partners including Dr. David Pedlar, the scientific director of the Canadian Institute for Military and Veteran Health Research.
My research in particular focuses on evidenced-based medicine, chronic pain, disability management, opioids and cannabis.
We note that military service is associated with health risks. Recent surveys have found 41% of military personnel report the experience of chronic pain and 23% report intermittent pain. Military personnel develop higher rates of psychiatric disorders such as PTSD and anxiety than members of the general public, and they are at greater risk for both suicide attempts and completion.
Regarding the potential role of medicinal cannabis to assist our veterans, we have at present moderate quality evidence that suggests cannabis may reduce chronic pain, but effects are typically modest. Our group here at McMaster is currently revising and updating this evidence synthesis. We anticipate our work will be completed in the first half of 2019.
Regarding the current evidence to support a therapeutic role and management of symptoms associated with anxiety or PTSD, we have anecdotes but we have very little evidence to make conclusions either supporting a benefit or refuting a role.
We have some observational evidence that has shown that, in areas where cannabis becomes available for medicinal use, suicide rates in general seem to track down. We also have observational evidence that veterans who present with cannabis use disorder are at higher risk for suicide attempts. This is another area where more research is needed before we can make firm conclusions.
There are a number of side effects associated with cannabis. These include dizziness, fatigue, euphoria, confusion, disorientation. Cannabis use disorder or addiction occurs in about 7% of regular users over their lifetime, and the adverse events associated with cannabis are predominantly tied to one cannabinoid, THC. The cannabis plant contains more than 100 active cannabinoids, the most studied of which being THC and CBD. CBD may have some therapeutic properties, but it is neither psychoactive nor addictive.
This suggests that cannabis products that contain predominantly CBD may be associated with much fewer adverse events than the plant as a whole. Despite the limited evidence for benefits and the known and suspected harms, the general perception about cannabis seems to be increasingly enthusiastic.
A 2017 survey of more than 16,000 Americans in the general public found that 81% believed cannabis had health benefits; 9% believed it had no risks; 22% believed it was not addictive. These perceptions are not in line with current evidence.
We also know that authorization for medicinal use is increasing in Canada. According to Health Canada's registry of patients, there were about 8,000 who were authorized to use medicinal cannabis in 2014, and at present this figure is closer to a quarter of a million. The rapidly expanding therapeutic use of cannabis suggests a triumph of marketing over evidence. I would suggest there may be some relevant lessons to be learned from Canada's experience with opioids for chronic pain.
At present, over 7,000 veterans in Canada have been authorized to receive medicinal cannabis, and the matter of dosing has been contentious. The precise dosing is not available from current evidence, and a dose of cannabis does not consider the potency, particularly the percentage of THC that may be available in a product. In addition to that, the product of cannabis can be consumed either through inhalation or through ingestion and the way in which you take it in affects both the time of onset and the duration of effects.
VAC currently reimburses up to three grams per day in general for medicinal cannabis and up to 10 grams with approval for exceptional cases. These are not excessively conservative policies relative to other countries. For example, Israel reimburses only one and a half grams per day, the Netherlands 0.68 grams per day. If you look at the data from Health Canada regarding how much cannabis those who are authorized to use it for medicinal purposes are currently accessing, on average it's about 0.75 grams per day. The likelihood of an individual consuming the very high end of what's allowed, 10 grams per day, suggests they are at higher risk for developing dependence and possibly cannabis use disorder. The result of this means that withdrawal symptoms would result if their dose were tapered rapidly or if the product were made unavailable to them, and as such there is a need for both caution and compassion considering veterans who are currently using medicinal cannabis, in particular at higher amounts.
What is needed to promote evidence-based authorization of medicinal cannabis? We need randomized controlled trials to establish effectiveness of cannabis for promising indications. Observational data, which is what we have most of, cannot establish causation, and such trials should enrol adequate numbers of patients to make firm conclusions, follow individuals for a long period of time, six months to a year, and consider capturing both benefits and harms of cannabis use. We require more real-world observational data at the same time. Veterans and other medicinal cannabis users can be enrolled in research cohorts and followed forward in time to look at patterns in change of use, the effect on their symptoms and the development of both long-term and rare events.
We also need guidelines to help veterans, other patients and clinicians make evidence-based decisions around medicinal cannabis. The most applicable area for this would be chronic pain. That's where we currently have the bulk of evidence for the application of medicinal cannabis.
At the same time, evidence alone is not sufficient to make clinical decisions. Because of the likely modest benefits, and the known and suspected adverse events, the decision to pursue a trial of therapeutic cannabis is not straightforward. We require values and preference research so we understand what patients are willing to trade off, given the evidence for potentially modest benefits and the development decision aids would help facilitate shared care decision-making.
On a positive note, with the dedication of appropriate resources, given the current legalization of cannabis and the interest in research, Canada has the opportunity to become an international leader in medicinal cannabis research for both veterans and in general.
In closing, I thank you for the opportunity to serve as a witness for this committee.