Veterans Affairs Committee on Feb. 25th, 2019

[Gord Johns, NDP, Courtenay—Alberni, BC]

To Mr. Samson's comments, actually the minister was initially scheduled through an email of the draft schedule to appear on February 27. We have not been formally told the minister will be here on March 18 until now. That is actually not true. I know there have been discussions in the back halls, but there's not been an email sent to anyone at this committee, nor has that been tabled here at the committee until right now.

[The Chair, Liberal, Neil Ellis]

Thank you for that.

Mr. McColeman.

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

To Mr. Samson, where was that information? We did not get that this was the case, because we have not heard either. We would say the same thing as my NDP colleague just said, that there was nothing we were told anywhere in writing or verbally that was the date we had scheduled the minister. Could I have an answer to that, please?

How did he know it?

[The Chair, Liberal, Neil Ellis]

I don't know if that information came to the clerk today. Did that come today? I don't think so

Let's call a vote on the amending motion.

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

No, Chair, I'm not letting—

[The Chair, Liberal, Neil Ellis]

Mr. Samson—

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

No, you know what? I listened to this member in the House, and I have to tell you, it upset me greatly because he took such an over-the-top aggressive approach to describing how we on this side of the House—

[A voice]

[Inaudible—Editor].

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

Look, it's my time to speak.

Now he has the audacity to come here and scold us, because we didn't know something that was never sent to us. I want an apology.

[The Chair, Liberal, Neil Ellis]

Okay, let's call the vote.

(Amendment agreed to)

(Motion as amended agreed to)

Now we can start with the witness testimony.

We have in front of us today GenCanBio Inc., Mark James, vice-president. As individuals we have Ramesh Zacharias, medical director at Hamilton Health Sciences and Tony P. George, professor of psychiatry at the University of Toronto. From Tilray, we have Philippe Lucas, vice-president, global patient research and access.

Since we have somebody from Sydney, Australia, we'll start the first round of testimony with Mr. Lucas, and hopefully we can keep this to around seven minutes.

Thank you.

[Philippe Lucas, Vice-President, Global Patient Research & Access, Tilray]

Thank you very much, Mr. Chair and members of the House.

My name is Philippe Lucas. I'm vice-president of patient research and access for Tilray. I'm also a graduate researcher with the Canadian Institute of Substance Use Research, and I'm vice-chair of the Cannabis Council of Canada, an industry association representing licensed producers in Canada.

I'm speaking to you today as a long-term patient advocate for medical cannabis patients. I've been working in the space for over 20 years, initially as a patient, then as a patient advocate and provider, and over the last five years in my role at Tilray. Tilray is a global pioneer in medical cannabis research and distribution. Our products are available in 13 countries on five continents right now.

Tilray has done much over the years to work with Canadian veterans to improve the lives of those who might benefit from the use of medical cannabis. We currently serve more than 500 veterans registered with Veterans Affairs Canada. We're the title sponsor of the Wounded Warrior Run B.C. and the Highway of Heroes Bike Ride. Ironically while we're speaking here today, the Wounded Warrior Run B.C. is on its second day, and you will see veterans—police, military and first responder veterans—running from the top of Vancouver Island down to Victoria over the next week, through sleet, snow and rain, to raise attention, awareness and funds for vets who might be affected by PTSD.

Tilray has put in place some very VAC-specific services to aid veterans who might benefit from the use of medical cannabis. Those include putting in VAC limits where we charge all veterans $8.50 per gram—a sort of discount cost on the grams of cannabis they order from Tilray—to ensure they have access to the full selection of products that they need. We have also put in place what we call the VAC bridge program, which allows vets to order cannabis before their VAC approval goes through, to ensure that veterans are not out of pocket when they're ordering medical cannabis. On top of that, we have VAC specialists on staff who can work through approvals, denials and reimbursements with those veterans.

We're a leader in medical cannabis research, and that includes doing a phase two clinical trial at the University of British Columbia on medical cannabis as a treatment for post-traumatic stress disorder. At 42 participants, that's the largest medical cannabis clinical trial to take place in Canada in at least the last four years, and the first medical cannabis clinical trial to examine the use of cannabis in the treatment of a mental health condition. Over the next few weeks, we'll be announcing a second site for that trial in British Columbia.

Today I want to share, very quickly, the results of the Canadian cannabis patient survey from 2017 that we ran. That survey at the time was the largest survey of Canadian patients to date, with 2,032 responses. I took this opportunity to break out the responses of patients who identified post-traumatic stress disorder as their primary condition.

What we see from these patients is that medical cannabis is primarily used in the treatment of chronic pain and mental health, but compared with other patients, those affected by post-traumatic stress disorder are more likely to be disabled. They're more likely than the general population to report use for anxiety, stress and depression rather than simply chronic pain. They're more likely to use cannabis daily, and to use more than the average patient—2.1 grams per day versus the 1.5 gram average of other medical cannabis patients. They're more likely to use cannabis extracts.

Also, perhaps most important to this committee in looking at the health and welfare of veterans, they're also more likely to reduce their use of opioids, antidepressants and benzodiazepines as a result of their use of medical cannabis. According to data from Veterans Affairs Canada, the recent significant increase in the number of veterans using medical cannabis is paralleled by a nearly 43% decrease in the number of veterans using benzodiazepines and a 31% decrease in the number of veterans using opioids.

Tilray has put in place VAC-specific services to assist Canadian veterans, and today we're here to urge you to reassure veterans of the government's commitment to covering the cost of medical cannabis for veterans who might benefit from its use. We're urging you to remove the punitive excise tax as well as the sales tax on medical cannabis that's affecting critically and chronically ill Canadians across the nation, and to increase research funding to examine the therapeutic potential of medical cannabis in the treatment of post-traumatic stress disorder, traumatic brain injury, mental health and chronic pain.

I look forward to your questions, and I really appreciate being invited to speak to the committee today.

[The Chair, Liberal, Neil Ellis]

Thank you.

Next, we'll have Mr. George, professor of psychiatry, University of Toronto.

Welcome, Mr. George.

[Dr. Tony P. George, Professor of Psychiatry, University of Toronto, As an Individual]

Thank you for having me.

It's a pleasure to be able to speak in front of this committee on veterans.

I'm a professor of psychiatry at the University of Toronto, and an addiction psychiatrist. I think the previous speaker covered a little bit of what I wanted to say.

I have been doing research for many years now on cannabis and mental illness, in particular on the harms that come with that. I have studied people with psychotic disorders like schizophrenia, mood and anxiety disorders like depression and bipolar disorder, and even post-traumatic stress disorder—PTSD. I think that now with legalization here there are tremendous opportunities to understand the effects both on the general population and on people with specific mental health disorders.

The preponderance of the evidence—and I'm very delighted that licensed producers are actually doing this research—actually suggests a fair amount of potential harm in people with psychotic and mood disorders. Even in the PTSD literature, this is quite mixed right now. Again, I applaud the research being done in this area. Moreover, I think the reduction in the compensable grams per day of medicinal cannabis from 10 to three grams was a step in the right direction by Veterans Affairs Canada, just because of these harms.

We know that these harms in particular relate to two things. Number one is the content of THC in cannabis. That's tetrahydrocannabinol, which produces the “high” and many of the positive effects but is also related to harm. The other thing that counteracts that is this other cannabinoid, CBD or cannabidiol. Essentially, the ratio of those two dictates safety. The lower the ratio, or the more CBD that's in cannabis of any form, recreational or medicinal, the more it's going to potentially lower the harms.

The other thing I just want to state is that whether folks are getting medicinal cannabis—our veterans who are getting medicinal—or using recreational cannabis, there is going to be a subset of them, probably between 3% and 5%, who develop cannabis use disorder, as we call it in the medical field. The key thing I want to state about that is that it's a treatable disorder. There aren't any medications yet approved for that, but there is a lot of research in treating problematic cannabis use. There are lots of behavioural therapies and talk therapies that are not widely accessible. If our veterans are going to be at risk for developing these disorders, we want to do everything we can to put evidence-based treatments in place so that we can treat problematic cannabis use. It doesn't have to be a psychiatrist or a psychologist. Any willing provider can do that.

In summary—and again, I want to thank you for having me billed to come to speak to you—I think there's tremendous progress that has been made in understanding medicinal cannabis. Now with recreational cannabis, it's very likely that we could see increases in the rates of overall use in the population, including in our veterans. We want to do everything we can to control or limit the amounts of THC because we know that at a certain point it's going to do harm, particularly with developing brains and for people who are at risk or who have existing psychiatric disorders and mental health issues. We have treatments that can work.

Thank you for the time and for having me.

[The Chair, Liberal, Neil Ellis]

Now, it's Mr. James.

[Mark James, Vice-President, GenCanBio Inc.]

Thank you.

First of all I want to thank the chair of the committee for giving me the opportunity to speak today. The subject is very close to my heart.

I am a businessman from Halifax, formerly from Fall River, Nova Scotia. I'm a retired RCAF pilot and a former combat arms officer as well. I had a career in the military spanning 35 years. Since then, I've also worked as a first responder in both search and rescue and firefighting.

Over the course of my military career I saw first-hand the mental and physical implications suffered by comrades from PTSD and chronic pain, so this is first-hand.

The bonds we forge in the military continue long after the uniform comes off, and as such, a business venture I became involved in as a co-founder is a company called GenCanBio. GenCanBio is a Nova Scotia company. We're dedicated to pre-clinical research on the interaction of various cannabinoids and terpenes and the efficacy of these ratios on specific conditions.

GenCanBio has been working on and investing in cannabis-related research into PTSD since 2015. Working with the National Research Council of Canada we've developed a high throughput assay to screen these cannabinoid ratios for conditions such as pain and anxiety. GenCanBio has since partnered with an Ontario-based pharmaceutical company called Ethicann for the development of ethical-based drugs based on botanical extracted cannabinoid oils for symptomatologies including PTSD.

Currently, veterans can purchase various forms of cannabis, but the batch-to-batch purity and potency lack the consistency of an approved pharmaceutical. None of my former comrades wants to get high; they want to get better and they want to be productive. GenCanBio and Ethicann believe strongly that smoked medical marijuana will no longer exist shortly. It will be replaced by a standardized, botanically sourced drug that has been subjected to the regulatory scrutiny of Health Canada, the FDA and other regulatory agencies.

Ethicann is currently working with the U.S. Army to develop a clinical protocol for PTSD. We've reached out to Dr. Cyd Courchesne, chief medical officer of Veterans Affairs. We met with her in early December 2018 to discuss PTSD in Canadian veterans and the need for a well-characterized cannabinoid pharmaceutical to treat them.

Dr. Courchesne facilitated for us the outreach to several Canadian PTSD researchers, including the Canadian Institute of Military and Veteran Health Research and the centre of excellence on PTSD and other related mental health conditions.

In January 2019, we met with Dr. Alice Aiken, who is the VP of research and innovation, and Sherry Stewart, professor of physiology and neuroscience at Dalhousie University in Halifax, both of whom are very excited to work with us on a clinical protocol for PTSD in conjunction with the U.S. and hopefully the Canadian militaries.

We are thus currently working with several Canadian licensed producers and extractors to develop pharmaceutical-grade APIs—an API is an active pharmaceutical ingredient—that can be formulated for clinical studies on veterans with clinically diagnosed PTSD symptoms. Having the support of Veterans Affairs to offset the cost and timelines of these efforts will greatly benefit Canadian veterans.

In closing, I wish to thank the chair and members of the committee for allowing us to express our views today. We believe and have seen that medical cannabis imparts great quality-of-life benefits to our wounded men and women, but I respectfully submit that there's an alternative and better delivery system for this, one that is more effective, more predictable and more cost-efficient. Working together, this is something we can make happen.

As such, I've included in my speaking notes—I'm not sure whether you received these—letters from the presidents of GenCanBio and Ethicann, with requests to continue this dialogue.

Thank you.

[The Chair, Liberal, Neil Ellis]

Dr. Zacharias.

[Dr. Ramesh Zacharias, Medical Director, Hamilton Health Sciences, As an Individual]

Mr. Chairman, good afternoon honourable members of the Standing Committee on Veterans Affairs addressing the issue of cannabis use among veterans and its effect on their well-being.

My name is Dr. Ramesh Zacharias. I am an assistant clinical professor in the department of anaesthesia at McMaster University. I'm also the medical director of the Michael G. DeGroote Pain Clinic. I'm also the co-chair of the physician advisory group for the centre for medicinal cannabis research at McMaster University.

It is truly my honour to address the issue of medicinal cannabis use by veterans and the impact on their well-being.

I'm going to frame my presentation around identifying three of the current challenges and propose three opportunities to ensure the safe and effective prescribing of cannabis.

The first challenge is what I call “the cart before the horse”. Since cannabis was legalized on October 17, 2018, the availability of cannabis for medical purposes was instituted prior to our understanding of the efficacy and safety in a variety of conditions. As a consequence, the medical claims are either overly positive or negative. On the one hand, cannabis is being viewed as a panacea with a cure-all for many medical ailments and at the same time, there are those who see legalization as a Pandora's box, the use of which predisposes the public to unknown harms.

I have been involved in prescribing cannabis for over 10 years. I am of the opinion that with the appropriate patient selection, the use of validated screening tools and informed prescribing, cannabis will be a benefit in a number of conditions.

Although anecdotal evidence has highlighted the potential beneficial role of cannabis for symptom management, such as pain, sleep, nightmares, anxiety and PTSD, the research community is far from having a complete understanding of the mechanisms of cannabis use for common health problems faced by Canadian veterans.

Second, in addition to my work at McMaster University and Hamilton Health Sciences, I have been an investigating coroner in the province of Ontario since 2012. Over that time period, I have either been the investigating coroner or the regional supervising coroner investigating over 1,000 cases. Sadly, a number of those were opioid-related deaths.

The majority of education that was provided to physicians with respect to the prescribing of opioids was provided by the pharmaceutical industry, and unfortunately today, the majority of education for health professionals completing medical documentation is once again being provided by the licensed producers.

The third challenge is the way cannabis is currently being prescribed in Canada. My practice involves looking after veterans. Unfortunately, a number of our veterans have received their medical documentation over Skype without actually being seen by a health practitioner in the office. Once the medical documentation was completed and submitted, they were then scheduled for a follow-up appointment in one year. I find it hard to believe that we as a society would support a process for prescribing any treatment for chronic disease over Skype, with a subsequent monitoring one year later.

Having laid out the challenges that we currently face in Canada, I would like to propose three solutions. I do believe we have a great opportunity to make changes in the way cannabis is currently being prescribed.

In order to address this issue, one year ago we established a data registry called DataCann. The purpose of it was to gather real-time prospective information on patients using medicinal cannabis. We collect information on their diagnosis for which they have been prescribed medicinal cannabis, but equally important, we use validated tools to assess overall functions: sleep, anxiety, depression, PTSD, as well as the early identification of those who could possibly develop cannabis use disorder.

I believe we have a great opportunity to monitor the effectiveness and safety of cannabis among veterans by having them enrolled in this registry voluntarily. This registry has been funded by the Michael G. DeGroote Pain Clinic, the national institute for pain, at McMaster University and the Centre for Medicinal Cannabis Research. We have received no funding from industry.

The second opportunity we have, if we want to learn from some of the mistakes of the opioid crisis, is that we need to develop Canadian guidelines for the prescribing of cannabis. The first Canadian opioid guidelines were developed 15 years after OxyContin was released. It is extremely important that we create evidence-based guidelines for all health practitioners who are prescribing cannabis. I think it would be important for this committee to encourage CIHR to fund the guideline development.

Finally, the federal government can play a significant role by supporting data collection today, as well as funding much-needed research. We have the infrastructure and a network of outstanding researchers in this country that, when funded appropriately, can give Canada a leading role in informing the dialogue about appropriate use of medical cannabis.

Once again, I would like to thank the chair and this committee for the honour you have given me in presenting to you today on this important topic.

[The Chair, Liberal, Neil Ellis]

Thank you.

We'll begin with five-minute rounds today.

Ms. Wagantall.

[Cathay Wagantall, Conservative, Yorkton—Melville, SK]

Thank you, Chair.

Thanks to all of you for your testimony today. I really appreciate it. I'm very grateful that we were able to hear from you.

Very quickly, on the committee here and as deputy shadow minister for veterans affairs, I talk to a lot of veterans specifically about this issue. In one example of many, a gentleman was bedridden for years. His wife would turn him over, feed him and give him his prescriptions: a thousand pills, pharmaceuticals, per month. Someone said to her, “Look, you have to at least try this.” She was getting the 10 grams before they changed it and would make a suppository, which is not for fun. She gave it to her husband.

The first time she gave it to him, she had an actual conversation with him within a half hour. She had not had one with him for years. Long story short, over time, he continued to improve. She wanted to take him off the pharmaceuticals he was on. She could not get the assistance of a psychologist or a doctor to do that. No one would help her with that step. She did it on her own, which was very frightening, as three of the prescriptions were stronger than opioids. Over time, he eventually walked into his doctor's office. His doctor's jaw hit the floor and he said, “I need to call all of my colleagues together because we need to speak with you.” This is typical, I think, of a lot of things that have been going on without the proper background and research, and without the proper education of our physicians on how to cope with these circumstances.

There are two things that I would like your response on, maybe from Dr. Zacharias first, and then I would ask the others to please come in as well.

How important is this research and that it not be impacted by funding? You say there's no industry funding in the research. I'm concerned that it doesn't become just another method of making a lot of money for pharmaceutical companies, rather than making sure that it's actually serving the way it's supposed to serve and having in place all of those checks and balances that you speak of.

[Dr. Ramesh Zacharias]

As I think I laid out, we have some challenges today. Part of that is the lack of knowledge among those who are prescribing it and also the lack of research towards understanding what works well. That was the reason we started our data registry: because we wanted to collect information up front on who's getting prescribed and how much, and what's happening to their medications. We track whether their medications are coming down. Has there been a change in what they're using?

Currently, we have 22 clinics across the country. Interestingly enough, 25% of patients on the registry are indigenous patients. We have a number of veterans who are on it, but I believe that now that we're prescribing cannabis to 9,000 veterans in this country, it would be extremely important for their well-being that we track what's actually happening to see whether their symptoms are getting better. There are a lot of stories just like what you told. Unfortunately, I've also seen a lot of disasters with cannabis as well, so I think collecting data in real time would be helpful.

We have a very robust research community in this country. Given the opportunity to fund them, I think they could address specifically the issue of what cannabis will work. I said earlier in my statement that I've been prescribing it for 10 years. In the right patient, with the right monitoring, it would be good.

[Cathay Wagantall, Conservative, Yorkton—Melville, SK]

Maybe, Dr. Lucas, you could respond to this.

In my province there is one doctor who would prescribe at the time that this individual was getting the help because they weren't prepared. Even if we get through all this research, what kind of a timeline are we looking at in terms of this being able to be handled with confidence by our physicians?

[Philippe Lucas]

I think there is encouraging news in that area. I've been working on this for over 20 years. I can remember when I knew all the doctors prescribing cannabis in Canada. You could count them on two hands. The latest report from Health Canada, from September, suggests over 18,000 physicians across Canada have prescribed cannabis at least once. That's a quarter of all physicians across Canada. Under those circumstances, it's hard not to think of medical cannabis as, in many ways, being a blockbuster treatment.

I completely agree that this is not the right treatment for all patients under all conditions. There are vulnerable populations out there, be they youth, women who may be pregnant or people with a predisposition for psychosis or schizophrenia, and of course we believe there should be some tracking to ensure the safety of those patients. It's one of the reasons that Tilray and patient groups have been advocating for pharmacy-based access to medical cannabis so that patients can get the benefit of a health care provider and get their advice as they pick up their cannabis, rather than just simply having it sent directly to the door, as is the case under the current system.

Licensed producers would love not to have to fund clinical research anymore. It's an expensive endeavour. That's why very few of us are doing it right now. There are 130 licensed producers in Canada. Only a couple of them are funding phase two or phase three clinical-style research. If the funding was available through the federal government, we'd be more than happy to make that available.

I also want to point out that like any clinical research project with academic affiliation, these studies have gone through rigorous ethics reviews, both via Health Canada and the academic institutions where they're taking place. In regard to our PTSD study, that would be the University of British Columbia. To mitigate any conflict of interest associated with funding or otherwise, we're completely separated from the data gathering, data analysis, associated with those studies. This is a very common practice, and we want to ensure that the data we collect is as independent as possible so that we can learn about the benefits and harms associated with medical cannabis.

[Cathay Wagantall, Conservative, Yorkton—Melville, SK]

Thank you.

Do I have more time?

[The Chair, Liberal, Neil Ellis]

No. Thank you.

Mr. Eyolfson.

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

Thank you, Mr. Chair.

Thank you to all the witnesses for coming.

I come from a medical background. I'm an emergency physician. I practised for 20 years. Coincidentally, Dr. Zacharias, I'm married to an anaesthetist.

I was glad to hear what you've been saying because I felt the same, although I was a supporter of legalizing for the recreational because I think the harms of the previous regimen were greatly outdoing the benefits. I was trying to find good medical evidence for it. I agree, some witnesses have said cannabis, in large part, although it has some use, has been more a triumph of marketing over science. I'm glad to hear you say that we need better evidence. We need a good, strong system because we want to do no harm, as the first part of the Hippocratic oath says.

I also really like your idea of a registry so that people who are having it prescribed can be tracked. I think that's a very good idea too. I think that's a good way we can get some research done.

Of the evidence that is there, what evidence do you know of on the use of cannabis for either pain or anxiety secondary to PTSD? What is the evidence that you're aware of on the benefits versus the harms in them, Tony?