Evidence of meeting #110 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 use.
A recording is available from Parliament.
4:40 p.m.
Conservative
Cathay Wagantall Conservative Yorkton—Melville, SK
Thank you.
I really do appreciate your testimony.
I would also like to ask Dr. Thirlwell, in regard to that, if she's had any interaction with veterans who have identified this. I also know of individuals for whom the neurofeedback has been phenomenal in assisting them to deal with that condition.
4:40 p.m.
Director, Sleep Wake Awareness Program
I think when we talk about randomized control trials and second- and third-level trials that doctors have to be very aware of—and for some reason medicine doesn't realize this—and know the state of the brain that they're dealing with.
Many of my patients have not just straight PTSI; they also have multiple concussions from being near IEDs. Definitely the mefloquine means another layer of sophistication is needed in terms of regimen protocols. The more complicated the trauma to the brain, the more levels that have been traumatized, the more precise and varied the regimens need to be and the more they need to have a wide breadth.
Many of my veterans with mefloquine toxicity will use three to four grams per day, three to four grams at night, and then have three grams available of many different strains that they've come to know and learn about.
Ultimately, cannabis medicine is personalized medicine. We need a different approach for practising medicine. The old paradigms are not going to work with cannabis.
4:40 p.m.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
Thank you, Mr. Chair.
Thank you to all of you for coming.
It's very interesting and valuable testimony.
We've heard from a number of witnesses about the amounts that are either beneficial or harmful.
Dr. Thirlwell, you were saying that on four to six grams a day.... What is the equivalent? Are you talking about the equivalent of dried cannabis? How is that four to six grams a day quantified?
4:40 p.m.
Director, Sleep Wake Awareness Program
We're talking about grams of dry flower. What I am referring to is what I was trying to make a point about at the beginning of my talk. A civilian brain runs at most at 400 or 500 kilometres an hour, let's say.
Three grams a day is fine for that, but not a military service brain or a traumatized brain. They need between five grams to eight grams at least, once they've been stabilized. The same way you have a lot of morphine post-surgery and then you wean down, in the initial stabilization phase, they need to be able to access eight grams to 10 grams regularly so they don't go into PTSD or anxiety about running out of medication and treatment.
4:40 p.m.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
Thank you.
We've had different testimony about the harms versus the benefits.
Dr. Walsh and Dr. Bonn-Miller, are you aware of any data on the risks versus benefits of the higher doses of more than three grams a day? We've heard some previous testimony which claimed that when you look at these higher doses in large numbers of patients, the risk of harm was higher than the benefit.
4:40 p.m.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
It was overall. Many of them were military patients.
4:40 p.m.
Perelman School of Medicine, University of Pennsylvania, As an Individual
Zach, do you want me to jump in first?
4:40 p.m.
Associate Professor, University of British Columbia, As an Individual
Go ahead.
4:40 p.m.
Perelman School of Medicine, University of Pennsylvania, As an Individual
I think it's interesting to talk about eight grams to 10 grams a day, or even three grams a day because there's really no science—truthfully, there's zero science—to back up eight grams to 10 grams a day being more beneficial than three grams a day.
How THC works is it's stored in the fat, so you're talking about pretty high amounts that build up in your body over time. All of the data right now are speaking to doses that are even lower than three grams a day being addictive. In our clinical trials, we're actually limiting it to 1.8 grams a day and seeing clinical benefit. I understand the [Technical difficulty—Editor] of using high doses, but that's a heck of a lot. That is not to say there's not individual viability here but that's an extreme amount of cannabis, honestly. It's much higher than what we're looking at in clinical trials in any of these studies. At levels that high, it's been associated with cannabis addiction and dependence, etc. It's worth throwing that out there.
4:45 p.m.
Associate Professor, University of British Columbia, As an Individual
In our trial, we're looking at about two grams of herbal cannabis a day. We do find that it's not uncommon for people to return that. We ask them to return whatever they don't use in a given day and sometimes they will bring some back. It's not like everyone is using all of their two grams per day.
Having said that, I do hear of cases where people do respond well to larger doses, as Dr. Thirlwell was discussing. I think the science is still unclear about what a maximum dose is. One thing we do know about cannabis and the endocannabinoid system is that it's what we call allostatic, which means it kind of regulates itself, so as you use more cannabis, you develop a tolerance and you need more cannabis to get some of the same effects.
That can lead to the tolerance and withdrawal that some people characterize as addiction. I want to use some caution about using the term “addiction” when we talk about medical cannabis users. There is a tolerance and withdrawal. It resolves itself more quickly than withdrawal from things like SSRIs, benzodiazepines and a number of widely used medications.
I want to caution the use of the term “addiction” in a medical context. The cannabis withdrawal syndrome is pronounced. There's no doubt that it exists, but it's also pretty mild in terms of the consequences and the difficulty people have giving it up. It's addictive, perhaps, the way that coffee is addictive, rather than the way that opioids or alcohol are addictive. There is a habit-forming aspect of it, but when we use the term “addiction”, it carries a lot of baggage. I just want to caution the use of that term when we talk about cannabis. There's a withdrawal and tolerance and I think one of the concerns about higher doses is that it can exacerbate that withdrawal and tolerance. That doesn't mean it's necessarily unmanageable. There are ways of titrating people down if the dose gets too high.
I do think it's worthwhile to consider those lower doses and see if people can't get the best effect at a lower dose. Perhaps, as we ramp it up, that can interfere with the optimal lowest possible dosing.
4:45 p.m.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
Thank you.
Dr. Walsh, you briefly touched on some of the patients, of course many with PTSD, PTSI, who will develop alcohol dependence or alcoholism.
Have you seen any correlation on the use of medical cannabis and the likelihood that someone will develop an alcohol dependence problem?
Will it give a protective effect and make them less likely to have alcohol dependence problems?
4:45 p.m.
Associate Professor, University of British Columbia, As an Individual
It's a very hard thing to tease apart in a prohibition framework. Some people talk about the gateway hypothesis where people start with cannabis and then they develop other problems. That's been largely debunked.
I think there is certainly a potential for cannabis to serve as a substitute for alcohol. I don't see it as a clear path where cannabis use is going to lead to an alcohol problem. I think it's more likely to lead as a pathway out of an alcohol problem.
4:45 p.m.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
Yes, that's what I was getting at. I wasn't suggesting it might make it more likely that it would. I was asking from the other direction. Would it make it less likely that you would develop an alcohol dependence problem if you were using cannabis therapeutically?
4:45 p.m.
Associate Professor, University of British Columbia, As an Individual
I think there is a possibility, if it's controlling the symptoms and if it's providing some of the effects that someone would want from alcohol. We're currently studying that in our lab.
With young adults anyway we've found they report that cannabis reduces their cravings for alcohol and their binge drinking. But that's research that really needs to be done. I think, in the context of young adults but also in the context of veterans it would be very important.
4:45 p.m.
Liberal
4:45 p.m.
NDP
Gord Johns NDP Courtenay—Alberni, BC
Thank you, all, for your testimony. It's very important.
Thank you for joining us from my office, Max. I really appreciate your making the effort today.
Max, you talked about your personal experience, moving away from pharmaceuticals to cannabis. Can you talk about some of the challenges and barriers you may have faced when dealing with Veterans Affairs Canada in getting cannabis and access to cannabis?
4:45 p.m.
As an Individual
It's nice to hear you, Gord.
I had zero issues whatsoever; however, I was guided through other veterans who weren't so lucky.
The way it works, from what I remember, is that you contact a middle company that deals between you and a licensed provider and they take care of all the paperwork. As you know, I can't read. It's not because I can't read; it's just that I can't focus long enough to read. I submitted all the paperwork required by Veterans Affairs. They handled all the paperwork through the licensed provider. The licensed provider contacts VA. In my case it was fairly painless.
I had a prescription for seven grams a day for the last three years, and when it got shot down to three grams, obviously it affected me, but not as much as the people who use the flower directly. I use an oil. I can use the flower to make the oil, which lasts longer because I don't need to use as much flower as oil. They are two completely different processes that go through the system.
To explain it a little—and the doctors might be able to explain it better than what I am saying—because it is processed through the liver, one dose lasts six to eight hours on average. That doesn't mean I won't need more in between, but on average, that's how I manage. I take a dose when I get up in the morning, at 7:30 or eight o'clock, and then it brings me to almost late afternoon. Then I manage usually during dinnertime for two or three hours and I'm still coasting, and then around 7:30—because it takes an hour to an hour and a half to process—I get into my nighttime schedule, which allows me to fall asleep.
I don't know for you guys, but for me a restful night's sleep is about six hours. That's the longest night's sleep I have ever had, and now we are talking medicated.
4:50 p.m.
NDP
Gord Johns NDP Courtenay—Alberni, BC
Max, can you talk about how the 10 grams to three grams has affected some of your veteran colleagues?
Dr. Thirlwell spoke heavily about the five to eight grams—I believe that's what she said—and its importance.
4:50 p.m.
As an Individual
I do have one of my friends whose brain is going to research. They don't even understand how he's alive, because of the damage. He got blown up twice. He uses, on average, 10 to 15 grams a day. However, I use a completely different method. He smokes; I don't. It works for him; it doesn't work for me.
That's the big thing to also understand. I've tried 12 to 15 different strains over the last three years. Another big thing to understand is that I actually have complete control over my medication. I know exactly how much I take at any given time. When I make my oil, I calculate my dosage. I regulate myself and control my intake. Some days I might need a little bit more. Some days I might need a little bit less. Dr. Walsh mentioned that over time you need more and more. It's absolutely true.
The big thing to understand with the seven grams a day is that it's not so much based on facts. In my instance, I need that to make my own oils. In order to make a normal batch for myself, I use about 60 grams to 90 grams of flower. That's three ounces. I have a 210 gram prescription, so that puts it in perspective. Out of those 60 grams, or 60,000 milligrams, I do about two cups, which is 500 millilitres. It's a ratio of how many milligrams per millilitre I can reach. With the sativa—I use an Alaskan strain because it works for me—I'm averaging about 25 milligrams to 30 milligrams, which is three times higher than people use for recreation.
I'm medicated right now, since this morning.
4:55 p.m.
NDP
Gord Johns NDP Courtenay—Alberni, BC
Max, I have a question. If you could flip a switch to change one thing at Veterans Affairs about their policy towards cannabis, what would that be?
4:55 p.m.
As an Individual
Go with what the need is. From what I understand from the doctors, I'm at the somewhat low end of use. For the guys who need the 10 grams, well, give them the 10 grams.
We're not just talking psychological. I have arthritis in every single joint in my body. I have back issues, knee issues. The big thing to understand about cannabis is that it does not get rid of the pain. It dulls it to a point where you can function, but you still know you are in pain, so you don't go past what you should be doing. That's where opioids fail completely, because they take the pain away. Then the member gets hurt, and so on. It's more of a management system versus a complete “zombification” of the member.
