Veterans Affairs Committee on Nov. 22nd, 2018

[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.

[The Chair, Liberal, Neil Ellis]

Thank you.

Mr. Zhang, you have 10 minutes.

[Dr. Yanbo Zhang, Assistant Professor, Psychiatry Department, University of Saskatchewan, As an Individual]

Good afternoon, bonjour, honourable members of the committee and my esteemed colleagues. I would like to express my sincerest gratitude for the honour to be here today.

My name is Dr. Yanbo Zhang. I am a clinician scientist from the department of psychiatry in the college of medicine at the University of Saskatchewan. As a psychiatrist, I treat patients with mental health conditions like depression, anxiety and PTSD. As a researcher, I use animal models to study the therapeutic effects and underlying mechanisms of cannabis as well as other normal treatments for psychiatric and neurological disorders such as depression, PTSD, multiple sclerosis and also traumatic brain injury.

I want to declare my funding sources and potential conflicts of interest. I received research grants from the University of Saskatchewan and also the Saskatchewan Health Research Foundation. I have an ongoing supply agreement from a cannabis company for my animal research, but the company does not influence my experiment design or the outcome of the research. I do not have any financial support or grants received from any industry.

I'm also the secretary-treasurer and the board executive for the Canadian Psychiatric Association. It’s a national professional organization for Canada's psychiatrists and trainees, but here all my opinions are my own, and I do not really represent any of our association’s opinions.

Military veterans have at least a twofold risk of developing PTSD when compared to the general Canadian population. Individuals with PTSD relive trauma through flashbacks and nightmares, and they suffer from extreme fear, irritability, hyper-arousal and negative emotions. Untreated PTSD causes severe and chronic impairment in their cognition, physical health and social functioning.

Psychotherapies are considered the primary interventions for PTSD. Trauma-focused cognitive behavioural therapy, called CBT, is by far the best supported method. CBT aims to change patients’ dysfunctional post-traumatic memories and beliefs and then to reduce or to decrease their response and avoidance towards the traumatic memory. However, due to the stigma, the service access, the cost and the time consumption, few patients engage in psychotherapy. Most patients with PTSD also receive medications like antidepressants, antipsychotics and mood stabilizers, but seldom stay on the medications due to side effects or lack of observed benefit.

Overall, the treatment of PTSD and the outcome are not promising. Studies also suggest that combat-related PTSD is more refractory to current treatments, which is probably due to high a comorbidity of brain injuries, chronic pain, addiction and also some other comorbidities. Medical cannabis has been allowed for PTSD treatment in a few countries, such as, Israel, Holland and Canada.

Although increasing preclinical studies suggest a critical role of the endocannabinoid system in PTSD and the potential of cannabis in treating PTSD, the clinical evidence remains inconsistent. Most trials have limitations, such as, a small sample size or the use of some healthy participants to elicit the anxiety symptoms rather than a real-world PTSD patient. They also use a synthesized cannabis product rather than the whole plant. In addition, the therapeutic dose range and the ratio of different compounds and their effects is unknown.

The systematic reviews, which are the strongest evidence that we normally use to guide treatment, cannot come with the conclusion of any definite therapeutic effects or benefits in terms of cannabis treatment for PTSD.

With little information, the physicians, pharmacists and patients cannot make an informed decision because there's no high quality of randomized and controlled trials on the whole planet of cannabis, which is the major product that has been distributed. It's really difficult for us to make a decision to see whether it should be used or not and what the benefit would be.

Also, there's consistent evidence showing that the heavy and regular use of cannabis with a high THC content is associated with increased risks of cognitive impairment, psychosis and cannabis use disorder, especially in adolescents and young adults, and also in individuals with pre-existing mental health conditions. Given the high comorbidity of depression, traumatic brain injury and substance abuse in veterans with PTSD, the potential benefit of cannabis may be shadowed by the increased risks of cognitive impairment and addiction.

As psychiatrists we are trained to practise evidence-based medicine, which requires us to examine the scientific evidence and to balance the risks and benefits before providing treatment. Thus, many psychiatrists, including myself, are really hesitant to authorize cannabis for treating any psychiatric disorders because we do not know the long-term outcome and we do not know whether the benefit will trump the risk.

On the other hand, effectively treating PTSD is quite a challenging thing. We have to explore new interventions that can benefit our patients. That's why it is critical to understand the therapeutic and adverse effects of cannabis products with different doses and with different ratios of THC and CBD. Research to compare the efficacy of cannabis use and also the currently available treatment, like antidepressants and psychotherapies, are highly needed, so we can find a benefits versus risks profile. Also, we need to determine the long-term effects of cannabis use on the patient's mental, physical and social functions, which is largely lacking at this stage.

The third part is we know that there's a high comorbidity of chronic pain and brain injury and substance use in patients with PTSD. They have a really complicated bidirectional relationship. Adding more studies on the interactions will help us to understand the prevention and the treatment options for the future.

Before obtaining further evidence, the low-risk cannabis use recommendations made by medical professionals should be applied, such as using a high CBD content oil versus using or smoking products with a high content of THC. I believe that the safe integration of medical cannabis can potentially improve the quality of care for the patient, but the robust, large-scale and blind and unbiased studies are needed to achieve this.

Thank you.

[The Chair, Liberal, Neil Ellis]

Mr. Cohen.

[Jacob Cohen, M.Sc. Student and Combat Veteran (Honorable discharge), Department of Pharmacology and Psychiatry, University of Saskatchewan, As an Individual]

Good afternoon, honourable members of the committee. There are no words to say how grateful I am to receive this experience to speak before you today.

I would like to talk to you about my experiences as a soldier, tell you about the obstacles we face as veterans when we seek treatment, and discuss the research I am doing with Dr. Zhang.

I would also like to say a big thank you to Dr. Robert Laprairie, who is a cannabis pharmacologist at the college of pharmacy who helped us review this, as well as Madam Kelly Malka from Montreal, who helped me a little with the translation to make sure it was correct.

I did a 1,000-hour primary care paramedic course at John Abbott College in Montreal. Then at age 19, I left to voluntarily join the military. I served with a light infantry regiment in a combat role as a combat medic, and then in 2013 the contract ended. It was up or out; I chose out and was honourably discharged.

I can say that I'm intimately familiar with PTSD, because unfortunately, I have different friends across the military, as well as EMS circles, who were affected in different ways. I know a paramedic instructor and a friend from the military who chose the permanent end to the temporary problem, which was suicide.

I can also say that the transition period is extremely difficult to live through. Many studies have shown that this period may be the most volatile and where there can be very prevalent use of substances.

In my case, I went from being mostly respected and appreciated as the company and platoon combat medic, to having extreme difficulties with licensing bodies to get back to work in a timely manner. Unfortunately, it's really common to hear about cases like this. That, combined with the fact that you're free to consume drugs and alcohol outside of the military or paramilitary organization that you belong to, is often the deadly concoction that leads to unemployment, homelessness, suicides and other devastating outcomes.

In the military, there's a very strong prevalent culture of substance abuse. Soldiers across the ranks often use alcohol as a tool to self-medicate, and even sometimes to let loose after a stressful deployment or stressful longer period. It's also not uncommon to see especially junior platoons be completely hungover for a 05:00 training session.

Also, many soldiers consume dangerous amounts of things like energy drinks and painkillers like acetaminophen and ibuprofen. They're often combined with cigarettes, chewing tobacco and energy drinks.

In my time, there was also a bit of use of synthetic cannabis. The product was called “spice”, which is a very high-content THC product that has negative effects. It couldn't be detected in urinalysis at that time. I think it can now, but I'm not sure.

Having said that, veterans are often their own worst enemy. There's a reluctance to seek treatment, and there's also some difficulty after service in connecting with others for different reasons. The desire for effects to happen right now hinders progress.

Many veterans who suffer from acute episodes of PTSD are often prescribed very powerful drugs like haloperidol and quetiapine, which are usually reserved for cases of severe psychiatric patients. This is an issue, since PTSD is very hard to diagnose, especially in the early stages, and is often comorbid with other conditions like anxiety, insomnia, chronic pain, hearing loss, tinnitus and others.

The stigma of being soft for seeking treatment, along with being given by physicians what many veterans refer to as the “zombie cocktail”, and being stubborn about treatment, can create a never-ending vicious cycle of distress between patient and clinician.

The fact that PTSD is also comorbid itself with different types of addiction is often a valid reason for physicians to be reluctant to prescribe drugs outside of the recommended guidelines, such as cannabis.

It was at that stage in my life I found that many people, especially veterans, talk but don't proactively take it upon themselves to change the solution. I saw also in friends that the symptoms were from very benign to very severe. For example, one just decided that he was going to defer medical school for a year and take some time off to calm down. At the other end of the spectrum, there were a few who needed intensive treatments, medications, and even hospitalization, for insomnia and nightmares in the early stages of PTSD.

I heard anecdotal evidence that there was some relief from these issues with medical cannabis. It was right when I got out. That's when the story of cannabidiol oil for the aggressive seizure condition, Dravet syndrome, really caught my attention.

I also came in contact with a man by the name of Boone Cutler. He was an American army soldier. A direct mortar impact caused a TBI and he found himself addicted to the very medications that the physicians at Walter Reed prescribed him. He switched to high-content CBD cannabis with THC as needed and has since become a radio host, author, columnist, video director and advocate in general. He made the Spartan pledge, which encourages veterans never to take their own life and “to find a mission to help my warfighter family”.

This led me to follow the military model to lead from the front and take it upon myself to study this. I took eight months after honourable discharge before going back. Even now in school student veterans are hardly seen and we're definitely under-represented just because there are hardly any veterans, period, or clubs on campus. It's also really hard to reach out.

Education on the subject is highly lacking. Even in the pharmacology program where I am now, there are still a few professors who are unaware that new technology has allowed for different compounds of the plant to be isolated and delivered in oil form within an accuracy of 0.01 milligrams per millilitre and as much as 0.25 milligrams per millilitre, depending on the company. Many are also unaware that companies registered with Health Canada as licensed producers usually have really strict guidelines to adhere to. The reputable ones, for example MedReleaf, Aurora, Canopy—I'm not endorsing them; I'm just saying—hold not only GMP but also ISO certification, which is a more strict form of regulation. They have many forms other than dried leaves, such as oils, edibles, vaping solutions and creams.

The issue, though, as both doctors have said, is that many studies and opinions contradict each other. There's not only a chasm between countries, but even within a province. For example, the CMA currently does not seem to support cannabis for PTSD. However, the Israeli Ministry of Health supports medical cannabis after traditional pharmacological options fail or if there's not enough help from psychotherapy within two months. In Israel they also recommend low doses of THC for severe PTSD.

Although patients can be authorized medical cannabis and seem to have reasonable insurance coverage, it's often very bureaucratic and confusing to begin the process since there are so many different requirements within each province, as well as at the federal level.

I believe we need more research into cannabis-based medicines so we can demonstrate their efficacy, if any, in individuals with PTSD. There is also a serious need to better educate health professionals as well as professors teaching these subjects so we can distinguish appropriate compounds from recreational and harmful use.

The current guidelines allow for three grams daily. When we think that this is enough to deliver half a gram of cannabis six times in an 18-hour period, it may seem like a lot but many patients, especially patients who have been to combat zones, may have more severe conditions and may require larger amounts, especially if they have a tolerance or if they're using smoked cannabis, since with smoked cannabis, the maximum bioavailability quoted in the literature that I could find was 56%.

At the moment powerful opioid drugs are prescribed to patients with chronic pain roughly every four hours according to the pain guidelines. Given that they're extremely dangerous and that it's also the driving force behind the current fentanyl epidemic in North America, to me it seems logical to allow for possibly higher doses in severe conditions, especially if they're using smoked cannabis.

Pharmacological information regarding dose responses by body weight, route of administration, and also the type of compounds is completely lacking, even non-existent. Studies in human patients are going to be needed to allow the full elucidation of cannabinoid pharmacology. The lack of treatment options without serious side effects and knowing that cannabis products were being used prior to legalization in both Canada and the United States led to my interest in studying cannabis as a potential therapeutic agent for PTSD.

Although it's a controversial topic, there is some anecdotal evidence of veterans using cannabis to alleviate the symptoms caused by mefloquine toxicity. I needed to determine and I hope to show that even if there are safety risks with cannabis, the benefits outweigh those risks.

During my undergrad I optimized an animal model of PTSD to mirror human exposures and conditions. Animals are subjected to daytime and nighttime exposure and then they get daily cage changes to simulate either a combat deployment, or an EMS shift with different personnel. Using this model, we have found that a low dose, five milligrams per kilogram, of CBD oil can really decrease the PTSD symptoms, and does not seem to have any addictive properties. Although the results are promising, it's still really early and we can't responsibly make any conclusions with respect to humans at this time. We do hope to explore different compounds, doses and ratios in both male and female rats before doing larger randomized clinical trials, hopefully with the Legion.

This is going to be the basis, and it's also the goal for my M.Sc. thesis. We think that more knowledge of the intricacies and mechanisms of our body's endocannabinoid systems will allow us to properly define optimal dosing for each strain and compound of the cannabis plant. Human studies into safety for pediatric conditions, such as Dravet syndrome epilepsy, as well as safety thresholds for cognitive effects when using THC are needed to make better decisions. We think these would benefit clinicians and patients alike.

Thank you.

[The Chair, Liberal, Neil Ellis]

Thank you.

Mr. Kitchen, you have six minutes.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you, Chair.

Thank you, gentlemen, for being here today. I really appreciate your coming and helping educate us on this issue.

I had the opportunity to meet Jacob.

I do believe, Dr. Busse, that I have met you before as well.

I was at the CIMVHR conference and I was enthralled by Dr. MacKillop's presentation on it. He, hopefully, will be here later.

Dr. Busse, I really enjoyed reading your guest editorial in the Journal of Military, Veteran and Family Health. It's extremely enlightening. I encourage everyone to read that. One of the things you talked about in there was how the legalization of medical cannabis was associated with reductions in opioid, antidepressant and anti-anxiety prescriptions. I'm wondering if you can expand on that to the committee.

[Dr. Jason Busse]

Absolutely. Thank you.

Where that information comes from is observational data looking at different states in the U.S. Currently in the U.S. there are approximately 30 states where they have legalized medicinal cannabis. There are currently another eight states that have legalized recreational cannabis. They've been able to do some time-series analysis. They've looked in these states at the rate of use of different prescription medications before legalization of medicinal cannabis and then after.

Because this is an observational study, there could be other factors that are affecting the use of prescription drugs, but in a number of states they've shown this pattern that the rate of use of prescription drugs and the rate of purchase of these drugs have gone down for drugs typically used to treat chronic pain, anxiety and depression. This doesn't give us enough evidence to say that cannabis is effective in treating these conditions, but it's an interesting and promising observational signal that suggests there could be therapeutic benefit, and that in some cases patients may be substituting their pharmaceutical drugs in place of medicinal cannabis and finding sufficient relief that they are staying with that product.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you, sir.

I commend all of you for talking about research and the value of it, especially for the potential benefits and the risks that are involved with cannabis use by not only our veterans but also others.

Dr. Zhang, you talked in your presentation about dried smoke cannabis with low bioavailability. When I listened to Dr. MacKillop's presentation, he talked a little about issues with synthetic cannabinoids. I'm wondering, obviously from an educational point of view, why there is a difference with synthetics versus dried product.

[Dr. Yanbo Zhang]

That is a really good point.

At the very beginning, when the synthetic one was developed, attempts were made to separate the useful compounds and then make them more precisely target the compounds in certain situations. However, more evidence shows that the synthetic ones may lead to a higher risk of psychosis. That's telling us that cannabis as a plant itself has complicated interactions between all those different compounds. So far, the most important parts are THC and CBD. The synthetic one is pretty much all THC without the counterpart of CBD, which is why there is an increased risk of all the side effects.

Even from our current guidelines or recommendations for the low-risk use, we recommend that people use the natural compound that has THC and CBD together rather than using a synthetic one.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

My understanding from that would be that the product that's out there for the general public, for recreational use, is higher in THC, whereas the medical marijuana would have higher CBD, which seems to have a better effect. Is that correct, or is that wrong?

[Dr. Yanbo Zhang]

The recreational one is quite a variety of products, so it's really difficult to compare. It depends on their strength and the customers' preference, but from a physician's perspective, when I am educating patients, I always tell them: CBD, CBD, CBD.

That's the message I'm sending out, because if you want to use cannabis to get high or for recreational use, you have to have THC. Otherwise, you won't get all the benefits you want. Why bother to use it?

However, when you are using it, the side effects and the long-term consequences probably won't be the consideration at that time. That's why I am even trying to persuade local governments and policy-makers to set a cap for the THC component. We know it's harmful, so why do we still want people to use it? If we could find a way for people to balance getting high and getting a feeling of relaxation without causing too much harm, that would be ideal.

[The Chair, Liberal, Neil Ellis]

Thank you, Mr. Kitchen. You're out of time.

Ms. Ludwig.

[Karen Ludwig]

Thank you for your testimony today.

I'm going to start with Mr. Cohen.

First of all, thank you for your service. It's quite rare for someone who has your experience and background to go on and become a pharmacology student studying for a master's, so thank you for doing that. That means a lot.

Looking at your pharmacology program, outside of the research that you're professionally conducting, is it part of the general curriculum in pharmacology to study the impacts and adverse effects and even cross-conflict between other medications and THC and cannabis?

[Jacob Cohen]

The short answer is no. There are some professors who have tried. They've provided decent information, but a lot of it I can actually go back and find with a Google search. The problem is that a lot of it is outdated.

For example, a few weeks ago there was actually a presentation where they discussed the number of compounds in the cannabis plant. The presenter quoted a figure from 2011, which was 60. We now know it's over 100, and I think there was just a study that came out the other week that said it's over 115 now. The issue is there's no formal program and information is often outdated.

[Karen Ludwig]

Thank you.

On Tuesday we had two doctors appear before us. I found it surprising, first of all, that they knew Veterans Affairs did not prescribe the drugs but, they said, certainly provided reimbursement. That much we knew. In terms of the authorizing specialists, though, such as the psychiatrists and medical professionals, they also said there's little training in medical schools regarding the prescription and uses of marijuana.

I'm wondering, Dr. Zhang, if you could also speak to that. If we think about any type of medication—because I see it as a medication in this case—when it's being prescribed, a significant amount of research is usually done on the impacts. Some people have very complicating situations. They could be taking other medications, or not realize the impact of consuming alcohol at the same time. Could you speak to that?

[Dr. Yanbo Zhang]

That's a really important issue. I think that, in general, the policy of marijuana use, and even recreational use, is faster than the evidence presented, not just nationally but internationally.

From that angle, medicine, and also psychiatry as part of medicine, is quite conservative in that way. Why is that? People's lives and people's function and quality of life are in our hands. That's why evidence-based medicine is the best we can get. Without that, it's very difficult to tell whether we're doing the right job to treat the patient. All medications have side effects but to a certain extent we know what's going to happen and how we're going to prevent it, which we discuss very thoroughly with our patients.

This is probably the only medication that's not been endorsed by Health Canada. It's not been approved for that but it's being authorized by physicians. We are in a dilemma, in a very dramatic situation. I know some patients might need it, but how could a physician like me go beyond the concept of no harm? The basic ethical thing for us is to cause no harm. Before I know whether it causes harm or not and I prescribe it...that's why I do not do it.

Also, we do not have any training. Our previous training was that it was bad. Suddenly now it's good, but we don't know how good it is. That's the dilemma.

[Karen Ludwig]

Mr. Cohen, what's the best way to get information to, let's say, a veteran who is using marijuana, maybe potentially even self-medicating—because as you said, Dr. Zhang, there is a difference in the strength of the THC between medical marijuana and recreational marijuana—so we know whoever is using it has the best information?

[Jacob Cohen]

Unfortunately, at the moment the biggest circulation I see of it is through social media and on Facebook, but, it's not bad information. It's surprisingly...there are some cautions, but I think the best way would be to educate people on where to find marijuana, and then perhaps somebody could produce literature or maybe even include it as a discharge package.

[Karen Ludwig]

Do I have more time?

[The Chair, Liberal, Neil Ellis]

You have 40 seconds.

[Karen Ludwig]

Dr. Busse, what you're suggesting I think is really important. Similar to Dr. Zhang and also to Mr. Cohen, you're emphasizing research and the work you've done.

Research will be critical as we move forward because we're talking about the health of individuals and no government goes into this lightly. We went into this in terms of support, to give people the best possible care.

If you could send any information or a brief on what you're recommending for research, maybe even look at it from a coordinated aspect, that would be very beneficial.

[Dr. Jason Busse]

I'd certainly be happy to do that.

One of the reasons we're in this funny situation is that usually before a product becomes available for therapeutic use, it has to undergo rigorous research, clinical trials, and you have to demonstrate the evidence that the risk profile is acceptable.

Medicinal cannabis has come onto the scene through a series of legal challenges. Now it's available, and we have to look for the evidence to see what it might work for and what it might not work for. In many ways, the cart has gone in front of the horse here.

In terms of looking at its potential interactions with other drugs, I think that's such a critical question. There is a network in Canada called DSEN, the drug safety and effectiveness network, and they capitalize on the use of large-scale data through ISIS to see where there are drug-drug interactions. Certainly we benefited from that greatly when looking at the opioid guideline for understanding the interaction with benzodiazepines and other sedating medications as a real contraindication. The trial that Mr. Cohen referred to of Dravet syndrome, they did find, with a high dose of CBD, the potential for interaction with other seizure medications.

It's early days but we have to look into it seriously.

[The Chair, Liberal, Neil Ellis]

Ms. Mathyssen, you have six minutes.

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

Thank you very much to everyone who's here.

It's interesting [Technical difficulty—Editor] that we collectively know or have been exposed to is anecdotal.

In regard to the training, I want to pick up from what Ms. Wagantall said, and with what you said, Dr. Zhang, about the lack of training.

How do we get past that? There's clearly a recognition. How do we provide that clinical training? Has the effort been made?