Veterans Affairs Committee on Feb. 25th, 2019

[Dr. Tony P. George]

That's a very important question. Cannabis affects on anxiety is somewhat indeterminate, whether it be within the context of PTSD or independent of that: generalized anxiety, panic anxiety, etc.

The preponderance of the studies has been not well-done one-time assessments, what we call cross-sectional, but generally those have been somewhat mixed. There are very few prospective studies whether of THC cannabis or CBD-rich cannabis. I think that's where we await the results of properly done clinical trials. Again, it's somewhat indeterminate, and what I worry a little about are anecdotal reports that might get overblown. That's why we need to do rigorous evidence-based studies. Whether it's academic investigators in universities or licensed producers, someone has to do this research and do it with rigour and transparency. Then we'll know the truth.

It has great potential, but let's get the facts behind it or not.

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

Okay.

Dr. Zacharias.

[Dr. Ramesh Zacharias]

There's moderate evidence of benefit in spasticity disorders and patients with MS. There's moderate evidence in chronic pain. There's weak evidence in anxiety, as well as sleep disorders. In educating people on prescribing, we have to be concerned that there are some red flags where you can see real challenges. Those are patients who have schizophrenia and bipolar disorder.

Part of the education that's required is to be able to bring that information out. Huge credit should be given to the Ontario Medical Association. Last October, they retained our research institute and we created the fundamentals of cannabis, module one, and a second one on pharmacokinetics and dynamics. They were distributed to the 36,000 doctors in Ontario. It's that kind of information that needs to be disseminated. Developing these education modules was funded by the OMA.

I think we're making very good progress, as has been reflected. We now have probably one in four physicians prescribing it. My only point is this: Are they prescribing it appropriately? That's the challenge that we need to address.

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

Thank you.

I believe that's my time.

[The Chair, Liberal, Neil Ellis]

Mr. Johns, you have five minutes.

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

Thank you.

I'll start with Mr. James. Thank you for your testimony. Thanks to all of the witnesses for your testimony.

You talked about some of the barriers for veterans accessing cannabis, and you talked about some of the alternative and beneficial.... Could you elaborate a little more about that? As a former veteran yourself and in terms of the barriers, can you talk about the importance of how we remove those barriers for veterans so they can access medicinal marijuana, and how that ties into opioid use? We see a lot of veterans who have been given prescriptions for opioids and pharmaceuticals—and we're seeing that shift over to cannabis as well—but it's important that veterans actually have that choice in their well-being and in their healing journey.

[Mark James]

Right. I didn't really speak about the barriers for veterans obtaining it. There are any number of ways that veterans can obtain cannabis.

First of all, from a doctor's perspective—I'm not a clinician and I'm not a physician—it just seems to me it would be very difficult for me as a physician to prescribe something that is impossible to dose properly. I have no idea what type of marijuana will be bought, what batch it will come from, how big a cigarette you're going to roll or how big a puff you'll take.

We're advocating moving towards a pharmaceutical product that is not smoked. We're talking more about a delivery system. We're talking about doing the research to get the right ratio of cannabinoids and terpenes into the pharmaceutical-grade product, and being able to administer it through a pill, a sublingual or skin patch, or that type of delivery system.

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

Dr. Zacharias, maybe you can elaborate on what Mr. James said in terms of the different types of progress that we've seen in science. Is Canada working with Australia or the U.S. in terms of the development of cannabis and different alternative methods of ingestion?

[Dr. Ramesh Zacharias]

I'm not sure who's working with whom, but I do know that there are various initiatives today to look at different delivery models. The folks from Tilray can probably address that better than me. I am aware of the initiatives. I'm just not closely tied to it.

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

Okay. Do you want to elaborate, Philippe?

[Philippe Lucas]

Tilray is involved in six clinical trials right now. I'm in Australia to meet with our team that's working on chemotherapy-induced nausea and vomiting. It's a capsule form of ingestion. It's worth mentioning that Tilray produces pharmaceutical-grade cannabis extract products, both as drops and as capsules, with a known dependable standardized source of THC and CBD from one batch to the next. This is as pharmaceutical grade as you're going to find. I'm pleased that patients are switching away from smoking and vaporization of cannabis more and more and our data clearly shows that they're moving toward the oral ingestion of higher CBD products.

I've recently been co-author of a paper looking specifically at cannabis and anxiety, which was published in the Journal of Psychiatric Research. The primary author of that study is Michael Van Ameringen from the DeGroote institute at McMaster. It's based on cross-sectional data, from the largest patient survey to take place in Canada at that time at 2,132 responses.

What we found was that over half of the patients cited a mental health condition as their reason for using medical cannabis—or at least as a symptom they were treating with medical cannabis—and for those who cited anxiety specifically, 92% reported that cannabis improved their symptoms. Nearly half reported replacing a non-psychiatric drug—opioids or other drugs—and about 46% reported replacing a psychiatric medicine with medical cannabis.

Right now, it's clear that we do need more data. We need clinical trials to get more information on this, so that's why we've moved forward with a PTSD study and we'll soon be announcing a study specifically looking at other mental health conditions with medical cannabis.

I agree that more data needs to be gathered, but right now, what we do know is that over half of the patients in Canada are citing that a mental health condition is being treated with medical cannabis. We feel based on that—and certainly with the reports that we're getting from veterans—the government needs to keep supporting that use to ensure cost is not an obstacle to access and to ensure the taxation is removed, so that it's available when needed. That's why pharmacy-based access is so important.

[The Chair, Liberal, Neil Ellis]

Thank you.

Mr. Samson, you have five minutes.

[Darrell Samson, Liberal, Sackville—Preston—Chezzetcook, NS]

Thank you very much, all four of you, for your presentations. Thank you very much for your patience. I understand it's such an important topic and your information is crucial to our study, so I thank you again for your patience concerning that.

As my colleague mentioned, it is sometimes difficult when we have testimony from individuals who are clearly able to articulate how it's helping them and their family, but then the other side of the coin is that we don't have the research to support it or we're saying so far we know it helps MS, it helps certain pieces, but it's.... I seem to be getting the notion that it's more of a one-to-one basis because you need to understand your patient as well.

Can a couple of you comment on that, please?

[Dr. Ramesh Zacharias]

Do you want to go first?

[Philippe Lucas]

I was just going to comment that almost everything we know about medical cannabis right now, we first found out through patient experiences. I've been working with patients for 20 years and when I started working with them in 1999, we didn't know anything about medical cannabis in the treatment of pain. We knew nothing about CBD being effective in the treatment of seizure disorder or pediatric epilepsy. We knew nothing about medical cannabis and its use for PTSD. Everything that we've learned about this, we've learned from patient experiences and, frankly, science is just trying to catch up now to that patient experience.

Sometimes, I get concerned when we start talking about this level of evidence as simply anecdotal. An anecdote would be if I said to you that my sister's husband said he cured his ingrown toenail with a cannabis tincture. It's very different when we have thousands of Canadian patients citing a specific level of efficacy or finding that they're getting relief from this kind of treatment, so as a social researcher, we cull that community to find evidence.

We need more research, obviously. We're eager to work with the government and academic institutions to do more research, but I get concerned, as I'm sure most physicians would be, when we start dismissing that patient experience. It's exactly what you're saying, Mr. Samson. We need to listen to the patients first and understand their stories and that can help guide the science down the road.

[Darrell Samson, Liberal, Sackville—Preston—Chezzetcook, NS]

Thank you.

Maybe one physician can share their feedback on that.

[Dr. Ramesh Zacharias]

Go ahead, Tony, if you want.

[Dr. Tony P. George]

I'm listening to this and I completely agree with what patients are saying. On the other hand, we want to make sure that what people are saying is supported by the facts.

I'll give you an example.

In the mental health field, anecdotes and some preliminary studies have suggested anti-anxiety, antidepressant effects of cannabis. These include studies on veterans mostly coming from the U.S.

One thing you have to realize is that someone who uses cannabis every day is likely physically dependent on it, and when they're not using it they go through withdrawal, which can masquerade as anxiety, depression and mood instability, and using cannabis can merely reverse those withdrawal symptoms. Doing rigorous, well-controlled studies is the only way to prove the case once and for all.

I love to listen to what my patients are saying. I love to be able to follow up and try to ensure that we optimize the treatment, but I also want to be a little skeptical about the kinds of things I'm hearing until I see well-controlled studies.

[Darrell Samson, Liberal, Sackville—Preston—Chezzetcook, NS]

Yes, but the testimony is helping us get the information we need to analyze and get the bigger picture.

Some groups believe that using cannabis for medical purposes can help reduce the use of other types of medications, such as opioids and benzodiazepines. Do you have any comments on that?

[Philippe Lucas]

It's actually my specialty area of research. I've been publishing on a phenomenon known as cannabis substitution effect for the last 12 years or so.

We have right now a longitudinal study taking place in 21 medical clinics across five provinces that is gathering data over a 12-month period on the impact of medical cannabis on more than 2,100 patients, with data points at baseline, one month, three months and six months, and it includes a very detailed prescription drug inventory.

What we see is a significant reduction in opioid use. About 30% of this patient population was using opioids at baseline. That reduces to 14% at six months, and the average dose of opioids from baseline to six months is reduced by 74%.

In light of the opioid overdose crisis that Canada and all of North America is facing, which is now starting to impact the rest of the world, it's hard to look at data like this without thinking that medical cannabis can play a role, if a limited role, in at least reducing the public health impacts of opioids on Canadian society and society elsewhere.

[The Chair, Liberal, Neil Ellis]

Mr. Bratina, please take five minutes.

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

Thank you very much.

I have to say I'm becoming confused, because we're hearing two sides of a very important story. Having heard Mr. Lucas just speak about the survey they're doing, Mr. Zacharias, tell me how that stands up to the clinical research you would be used to doing.

[Dr. Ramesh Zacharias]

When we have looked at the literature published so far—and I haven't looked at the literature that has just come out on sleep and anxiety—the evidence we have seen would be moderate for certain conditions and weak for others. Over time, I think part of the challenge is going to be selecting what patients you're prescribing these drugs for. If somebody has anxiety and also has bipolar disorder and possibly schizophrenia, you're going to see a huge difference from what you would see in somebody who just has anxiety.

The veteran population is quite interesting. From 2000 to 2005 I was looking after military personnel, and from 2012 to now—seven years—I've been looking after veterans. It's a completely different population from non-veterans in terms of the comorbidities and the challenges they've had being in theatre. They're a completely different group.

Part of the reason we wanted to separate the data collection is that things that might apply to the general public may be different. I still maintain what I shared earlier. I think the information isn't absolutely clear at the present time. The fog is lifting, and over time, we will have a better idea.

I think the dialogue between industry, which has been funding some of the projects, and the federal government will be quite different five years from now from what it is today, but it won't be any different if we don't learn the lessons from our mistakes in the past.

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

How long has cannabis been under scrutiny at the DeGroote clinic?

[Dr. Ramesh Zacharias]

I've been the medical director at the clinic since 2012. My practice has been around pain for 14 years now, mostly chronic pain. I can tell you it's very rare today for a patient to come looking for opioids. The most common drug they're looking for is cannabis. There has been a tremendous shift in what they're looking at.

I can speak only to my own experience. I've been prescribing it for over 10 years now. I have seen the benefits, but I'm also going to tell you I have seen some challenges, including in veterans.