Evidence of meeting #111 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 medical.
A recording is available from Parliament.
Liberal
The Chair Liberal Neil Ellis
I would like to call the meeting to order.
Today we have a panel with Dr. Oyedeji Ayonrinde, associate professor, Department of Psychiatry, Queen's University; and Dr. Yasmin Hurd, professor of psychiatry and neuroscience at the Icahn School of Medicine at Mount Sinai.
As individuals, we have Dr. Didier Jutras-Aswad, psychiatrist, Centre hospitalier de l'Université de Montréal; and Andrew Baldwin-Brown, co-founder, Spartan Wellness.
We will begin with your testimony, Dr. Ayonrinde.
Dr. Oyedeji Ayonrinde Associate Professor, Department of Psychiatry, Queen's University, As an Individual
Thank you.
Good afternoon, honourable members of Parliament. Thank you for the invitation to address this committee on the important topic of medical cannabis and veterans' well-being.
At Queen's University, Kingston, I'm an associate professor of psychiatry and medical director of the early psychosis intervention program for southeastern Ontario. I also hold a cross-departmental position with the department of psychology, and hold accreditations in psychiatry and addictions.
My cannabis-related research explores knowledge, attitudes and perceived benefits of cannabis across different demographic groups; cannabis use and mental disorders, primarily psychosis, anxiety and PTSD; and the objective quantification of cannabis products. Against this backdrop, we're developing a cannabis consult clinic, applying current evidence to reducing the risk of harms in youth and young adults.
I've also been involved in a number of initiatives with the Canadian Armed Forces, Health Canada and health professionals toward better understanding of cannabis products and potential impacts on mental health in some individuals.
The military veterans and their families make incredible sacrifices through the course of their careers, and in some cases for many years after active duty. As a psychiatrist who has worked with a number of veterans and their families over the years, I'd like to acknowledge this sacrifice; health consequences in some cases being physical, psychological or both.
I support evidence-based and objective decision-making by informed adults for both medical and recreational use, while advocating minimizing the risk of harms in children, adolescents and young people.
While cannabis products have been consumed for medical purposes for centuries, the scientific evidence base supporting its use at the same level of rigour as medicines and pharmaceutical preparations is still in relative infancy. There's a growing body of evidence regarding medical effects of cannabis. However, considerably more research is required. Some of the current cannabis legislative frameworks serve to position Canada as a leader in this sphere. Likewise, the anecdotal reports of individuals consuming cannabis for symptom relief cannot be ignored, as history has taught us with the development of other medications.
For my presentation, I would like to present the framework around medical cannabis using three Ps: the patient, the physician and the plant as a pill. The patient, with individual idiosyncrasies, includes comorbidities, family impact and socio-economic factors that influence health or well-being. I will speak about physicians, their experience, knowledge and attitudes, and cannabis, a plant as a pill for medical use.
With regard to the patient, in my experience in working with veterans, I would like to make a few observations, perhaps stating the most obvious. Veterans with health issues sometimes struggle with adjustment and negotiating their new identity and roles outside the military, including children, parents, partners and peer support systems.
Veterans range from individuals in late adolescence to elderly members of our communities. With these age differences are also significant differences in physical brain maturity—below the age of 25, in some—and the mental impact of exposure to different substances and situations. Furthermore, different military may influence trauma exposure or re-exposure. This exposure and individual responses are not homogeneous.
For instance, PTSD, a mental disorder, has unique subjective and experiential components for each individual that cannot be generalized. This is also the case with pain and sleep symptoms. Individual distribution of endocannabinoid systems within the body also have an interplay with cannabis that is unique to each of us.
As a pill, there's no single cannabis, and reference of cannabis indicates a very broad and heterogeneous range of plant product with shared core components in different ratios. While we refer to THC and CBD, there are many others as well.
On standardization, while some licensed cannabis products such as gels have been developed to stringent standards, the quantification and standardization of other products, such as dried flower, are less exacting. For instance, there can be considerable difference in the composition of a smoked joint with different joint sizes, THC potency, THC-to-CBD ratios and terpene profiles. Some early findings from research I'm doing at the moment have identified close to a 65-fold difference in the THC milligram potency of some joints compared to others.
With respect to dosaging, several factors can have an effect on the dose of active cannabis product delivered to the body: potency, quantity consumed, route of consumption—whether it's smoked, ingested or topical application—and individual tolerance. Furthermore, with smoking, significant dose differences can be achieved with different inhalation methods, such as the mouth hold and the puff frequency, to mention two. In light of this, more research needs to be done to identify optimum doses or dosing regimes for individual disorders and consumption styles.
Turning to side effects, like many products consumed for medical purposes, cannabis can present a range of adverse or side effects. Some of these may be genetically determined, such as the risk of psychosis in some individuals, while others may show direct dose response effects. In addition, adverse effects may reflect the product ratios, and this needs to be studied in greater detail.
On drug interactions, a number of veterans received treatment for different health conditions that may or may not be directly related to military duty. For instance, an individual with PTSD, heart disease and respiratory difficulties may be on multiple medications, requiring specialists' interventions. Drug interactions can have an influence on the overall effectiveness of multiple health condition interventions when different substances are used with cannabis.
In terms of risk versus benefit, with each medical cannabis product, route of consumption and application require careful thought regarding the risk versus the benefits, and it's not uncommon for individuals to tolerate harmful effects because the benefits override.
The next P is the physician or health professional. Many, if not the majority of physicians, have had only limited exposure to military medicine. The limited awareness of military experience among physicians can present a therapeutic gap. In light of this, the veteran seeking help is faced with bridging this gap with a health professional. The development of medical curricula in military medicine or a faculty of veterans involved in medical education may serve to bridge this gap, and invariably the experience of care. In addition, physician experience with cannabinoids is also quite limited, with some historical bias from the days of having to say cannabis was bad for you.
Next, I'll speak to the inadequate evidence to support clinical confidence and the absence of drug identification numbers from cannabis products. The range of cannabinoids and their effects require considerably more medical education and training. With authorization, and the use of cannabis from a licensed producer, the patients and health professionals are better informed of the content produced, with a duty to monitor response and effects. The development of support of centrally funded centres of research excellence in veteran health could enhance this, such as the Canadian Institute for Military and Veteran Health Research, CIMVHR, and international collaborations.
I have some brief comments on the study topics. As the study topics are far-reaching, I will limit my comments to those within the scope of my knowledge and understanding.
As mentioned earlier, the number of grams, for instance, three grams of dried flower, presents a very broad and unstandardized range of THC potencies and THC-to-CBD ratios, allowing for individual differences in health conditions, metabolism and tolerance. While this may be considered heavy consumption for recreational use, there's a distinction with specific symptom reduction and medical use, and we need more research to understand this better.
Current research regarding the use for PTSD and chronic pain shows that with PTSD there's emerging evidence of benefit in some individuals; however, larger randomized controlled trials are lacking, and studies require more specific dosage and composition data. For instance, frequent use of high-potency THC cannabis in a younger veteran may trigger psychotic symptoms, or worsen mental health, particularly if there is a family history. Given these points, the evidence is inconclusive and should be considered on an individual basis for now.
With respect to access to health practitioners to obtain medical authorization, there's a dearth of health professionals with in-depth understanding of military or veterans' well-being to provide specific medical authorizations for cannabis. With regard to veterans, a specific training and accreditation program for physicians, in conjunction with relevant medical colleges, may serve to bridge this gap.
Turning to the effect of legalization of cannabis for recreational purposes on the use of medical cannabis for veterans, this presents both challenges and benefits to understanding the use of medical cannabis. Research into recreational use allows a much better understanding of the physiological response, dosage effects and side effects of cannabis on healthy individuals and across the health spectrum. This new knowledge will ultimately benefit medical cannabis science. With veterans, the potential consumption of both medical and recreational cannabis concurrently can pose challenges with dosing and monitoring.
Additional thoughts would be on the development of a national information registry and specific advisory information for the military, and sensitively designed and tailored information campaigns for military families.
In conclusion, these are my preliminary thoughts on the study topics, and I look forward to answering questions or clarifying any points made. Thank you for the opportunity to share them with you.
Dr. Yasmin Hurd Professor, Psychiatry, Neuroscience, Icahn School of Medicine at Mount Sinai, As an Individual
Thank you for the invitation to speak on this very important topic, which is so critical to veterans and our society.
I'm Yasmin Hurd. I'm the director of the Addiction Institute at the Icahn School of Medicine in New York. I'm also a professor in psychiatry, neuroscience and pharmacological sciences. I'm also a neuroscientist whose cannabinoid studies have been recognized internationally in consideration of opioid reduction and related psychiatric disorders.
Veterans have always been trailblazers fighting for freedoms that we sometimes take for granted. Unfortunately, in some situations, this has placed them at tremendous risk even when the battle on the field is over. Many of them face a new battle, one even greater than the physical battlefield. A significant percentage of veterans suffer from PTSD, depression, chronic pain and substance use disorder. They are all interconnected. For example, chronic pain led many down the path of prescription opioids. Veterans, like many others, were simply unaware of the potential consequences of such potent opioids—including the tragic risk of addiction. We now know that the use of opioids over a long period of time is highly addictive, which has caused the deaths of millions of people in North America, as well as a significant economic burden and the destruction of many families and communities.
Cannabis has been proposed as a new pharmacological agent to alleviate the mental and physical suffering of veterans. Despite limited scientific research, cannabis use has been widely publicized as reducing chronic pain, PTSD, anxiety and opioid addiction. This really has unfortunate consequences since the public and veterans falsely believe that marijuana can cure all of these conditions.
As a scientist, I initiated the studies of cannabidiol, CBD, a non-intoxicating cannabinoid, as a potential treatment for opioid abuse more than 10 years ago now. Indeed, we observed efficacy to reduce anxiety and opioid craving. However, such studies are still in early stages of development and require more support. There is still a lack of substantial research evidence about the efficacy of cannabis to treat all these disorders, yet anecdotal stories have propelled many people, including veterans, to start smoking marijuana. Smoking anything has significant health risks.
Instead of science-based medicines, it seems that the Canadian marketplace has developed without the required clinical trials and research that's really necessary to establish the safety and efficacy of these new cannabis health products. Therefore, veterans, like many in our society, falsely believe that recreational cannabis and medical cannabis are one and the same. They are not.
There really is an urgent need for proper education all around. We must be committed to doing the necessary clinical trials and partnering with non-recreational licensed producers to develop real, safe and efficacious medicines that the veterans administration can truly support for the treatment of veterans. The veterans administration needs to identify those companies truly committed to developing medicine.
We must also develop formulations that are medicinal. We must know the cannabinoids, such as CBD or full-spectrum cannabis signatures, the dose and concentrations, which was spoken about before, the dosing regimen and the delivery formats, such as capsules or inhalation, that work best to maintain stable relief of pain, PTSD and addiction while minimizing the side effects. We do not want to, once again, put veterans at risk because we are rushing to put out recreational marijuana as medicine. While it is easy to pass off recreational joints to veterans as medicine, it really is egregious and actually an insult to veterans who deserve much more.
By working together, I fully believe that scientists, physicians, non-recreational licensed producers and the veterans administration can develop evidence-based medicinal cannabis. I think that veterans and the general society deserve nothing less.
I have addressed a number of the points that were raised with regard to the aspect of exceeding three grams a day and the cost of the reimbursement. I can't speak to the reimbursement so much, but in terms of three grams a day, I think the aspect of standardization is critical. Three grams indicates that it's about smoking. As I indicated, for me and most people in this field, smoking is not a valid medical route of administration.
If we're creating medicines, we should create the best formulations so that we can know what doses, concentrations and dosing regimens really alleviate specific symptoms and disorders. One dose will not fit all.
There is very limited research about which particular cannabinoids, or the full cannabis plant, are needed for each of these. Again, that's why it requires more research.
Without placebo-controlled double-blind clinical studies, we will not be able to give informed information to patients and physicians.
In closing, I definitely want to emphasize overall the critical need for veterans and the public to be made aware that for cannabis to be used as a medicine, we must treat it as such. The sacrifices that veterans have made should be honoured by bringing whatever is needed to provide them with safe, evidenced-based medicines. I really think that we can be trailblazers in developing such medications together.
Thank you.
Dr. Didier Jutras-Aswad Addiction Psychiatrist and Researcher, Centre hospitalier de l'Université de Montréal, As an Individual
I'll be speaking to you in French, and I can then answer your questions in both languages.
I want to thank the committee for inviting me to appear today to discuss an extremely important issue that affects thousands of men and women who have served this country. These citizens deserve not only our respect, but also access to care that meets their needs, both during and after their years of service.
I'll start by introducing myself. My name is Didier Jutras-Aswad. I'm an addiction psychiatrist and a researcher at the CHUM Research Centre, where I'm the head of a mental health and addiction research program. The program focuses specifically on cannabis and cannabinoids, and looks at both their harmful and sometimes therapeutic effects. I'm also the head of the Centre for expertise and collaboration in concurrent mental health and addiction disorders at the Université de Montréal, where I'm an associate professor in the department of psychiatry and addiction studies.
I'd like to start by establishing an important premise for this presentation. I believe that cannabis—as my colleagues have pointed out—is a complex substance that can have positive effects for some people, but harmful effects for others. I believe that both the dramatization of the negative effects and the excessive promotion of the therapeutic effects, which are often not scientifically proven, are counterproductive when it comes to addressing the many and sometimes complex issues concerning this substance. I hope to present to you today a balanced approach to a very important topic, namely, the proper use of therapeutic cannabis by veterans.
The appropriate choice of prescription for a treatment—as with many other medical conditions—is usually based on a careful review of the risk-benefit ratio of the proposed treatment.
In the case of medical cannabis, a number of so-called pleasant or soothing effects have been reported by users for a range of health issues. Some of these benefits have been studied and supported by scientific data, but others have not. The data that provides a more scientific perspective comes from studies that use various methodologies. These methodologies often include the administration of cannabis in the form of products with well-controlled doses and concentrations, and not cannabis smoked ad libitum without any control over the frequency, intensity and dose consumed by the user.
The health issues for which smoked cannabis has thoroughly demonstrated its effectiveness include chronic pain and a lack of appetite in people who have other disorders. The amount of cannabis involved is generally no more than one or two grams in most cases. Other health issues that can sometimes be adequately treated with non-smoked cannabinoids, such as tablets or inhalers, are most often nausea, spasticity and insomnia.
The risks sometimes associated with cannabis are becoming better known. While most people use cannabis without experiencing any issues, it can still have a negative impact in some situations. It can affect mental health in particular, by leading to symptoms of anxiety and depression, cognitive impairment, the development of psychotic presentations or symptoms of psychosis, or the development of a pattern of uncontrolled cannabis use. We're obviously talking about drug addiction here. All these risks are influenced by a number of factors. These factors are the person's individual profile, in particular the person's genetics, psychological profile, the context or time of use, the type of cannabis used, or the frequency and intensity of use.
I'd like to draw your attention to the fact that the use of the more potent cannabis—with high THC levels—or regular use, such as several times a week or every day, is often associated with an increased risk of developing issues related to the substance, particularly mental health issues.
I believe that all this information combined helps us identify the four conditions under which access to therapeutic cannabis has a greater chance of presenting more benefits than risks for veterans.
The first condition is the prescription of cannabis only after a thorough assessment of the underlying medical issue and the use of cannabis only for health issues for which we have enough data.
On that note, we have data from various studies that shows that the assessment conducted before the prescription or authorization of medical cannabis often lacks rigour. We also know that many of the people who use cannabis for therapeutic purposes will do so for health issues for which we don't have enough scientific data.
The second condition is the use of the most evidence-based treatments that follow the good clinical practice guidelines for the different health issues in question. In most cases, cannabis shouldn't be a first-line treatment for veterans.
The third condition is the administration of cannabis in the form for which sufficient data is available. In most cases, the smoked form shouldn't be the preferred cannabinoid form.
The fourth condition is the administration of cannabis in controlled doses, at the lowest possible dose to minimize the risk of side effects. Clinical attention must be paid to the concentrations and the frequency of administration, as is the case for any medical treatment. I'd like to mention here that the scientific data is weak and often non-existent for doses above one or two grams a day.
Lastly, I'd like to remind you how often veterans experience physical or mental health issues and addiction. Most of these issues can be treated through various forms of psychotherapy or through certain drug therapies. However, these treatments aren't always available to veterans. In many cases, cannabis is most likely not the preferred first-line treatment to properly help veterans. That said, and particularly when we're talking about tightening up the procedures for regulating access to therapeutic cannabis, it seems more important than ever to ensure that veterans have better access to care or services that are known to be effective.
I'll be pleased to answer your questions during the question and answer period.
Liberal
The Chair Liberal Neil Ellis
Thank you.
From Spartan Wellness, we have Andrew Baldwin-Brown, a co-founder.
Andrew Baldwin-Brown Co-Founder, Spartan Wellness
Hello. I'd like to thank you for inviting me to speak with you today.
I am Master Corporal (Retired) Andrew Baldwin-Brown. I enrolled in the forces in September 2001. I was a signaller. I did three tours in Afghanistan in the first six years of my service. I was diagnosed with post-traumatic stress disorder in 2012 and was subsequently medically released in October 2015.
I tried many SSRIs for depression and post-traumatic stress disorder, chronic pain in my lower back and in my knees. I didn't seem to find what I would call effective relief. I was more or less in a haze for about three or four years. I found that traditional medications didn't offer me the ability to feel either positive or negative emotions and it really negatively impacted my ability to get quality care.
Since then, as I said, I medically retired in October 2015. I've been a prescribed medical cannabis patient since January of that year. I had totally given up on the pill route.
Since then, I and eight other veterans co-founded a company called Spartan Wellness after seeing marked turnarounds in other patients, other veterans, in their quality of life, their ability to interact with their families, and keep up with commitments, both at home and outside. We decided it was time to actually take medical cannabis, as veterans, and take it back in-house, if you will, to take care of our own,
Currently, we have nine co-founders, all veterans, 26 veteran educators across the country, as well as the wife of a still-serving member who is taking care of our administration. A retired medic from the joint task force who did 16 years there is our medical director. We're hiring nurse practitioners who served in the forces as well.
When veterans come to us, they are processed administratively by a veteran, prescribed by a veteran, overseen by a veteran, and educated by a veteran on the way out. We feel there is nobody else in a better situation than us to help guide those patients. We have found that the difference in the quality of life is night and day. The veterans are, number one, staying alive. As I said, they are able to keep their family commitments and actually absorb proper treatment from psychiatric and psychological care as well as deal with their physical needs. They are able to get to physiotherapy. They are able to get to their doctors' appointments and they are actually improving.
That's pretty much all I have to say. I'm here to answer your questions more than to speak on what I do.
Thank you very much for having me here.
Liberal
The Chair Liberal Neil Ellis
Before we start the questions, we have to welcome a new member.
I didn't realize, Ms. Blaney, that you're filling in permanently now, so you can't leave.
Is there anything we have to do for that?
The Clerk of the Committee Mr. Michael MacPherson
We have to elect her as second vice-chair.
Liberal
The Chair Liberal Neil Ellis
Okay.
(Motion agreed to)
Thank you.
Mr. McColeman, we'll start with you.
Conservative
Phil McColeman Conservative Brantford—Brant, ON
Chair, I'd like you to give me a notice when I have one minute left in my questioning.
Conservative
Phil McColeman Conservative Brantford—Brant, ON
There's something procedurally that I need to introduce to the committee and I'm going to use my question period, which allows me to ask specific questions of you and then at the end, I will move on to committee business. It should not take a long time, but I just wanted to keep you informed.
In full disclosure, I've been studying the use of cannabis in the Dravet community for probably over 10 years and have seen the anecdotal information. Some people describe it as Dravet syndrome, but it's largely, the doctors will know, a seizure issue often with children who experience uncontrollable seizures. That community across the country—I have been to one of their national conferences—is convinced that the CBD product hasn't prevented or cured the seizure situation, but in some cases, according to individuals I've visited, it has reduced their children's seizures from 45 a day down to three. They're organized both in the United States and Canada.
Also, I have a special needs, disabled son who has experimented with cannabis oil for anxiety issues and episodic aggression.
I definitely agree with all of you that there's so little scientific research on the subject matter. I thank all the doctors because I see the common thread in your comments. You've also heard each other today comment that this is, at best, a trial that's going on in all of society as to what the benefits are. Some people are trying to grasp it.
The other distinction that was made by your testimony today is that there's medical cannabis and there's recreational cannabis. Of course, the current government decided to move forward with recreational marijuana, without the evidence in front of them of what the effects would be. Many people, including the medical community, were not in agreement because it was a premature step to take in terms of legalizing it. Also, my riding has the largest first nation in Canada, Six Nations of the Grand River, and they are rampantly going into production. This past weekend I met an individual who thought he was buying a CBD product in a liquid form to reduce his pain. I asked him if he knew what he was taking. He said he had no idea what he was taking. There are no labels on the bottle. They're completely out of the jurisdiction of the Government of Canada because they consider themselves to be an independent nation.
We have all this going on and I'm describing it in the context here. There's one issue that industry seems to be pushing right now and I want your thoughts and honest views on it. There's medical, which is not really prescribed, but it's recommended and that's been talked about as medical cannabis. The taxation regime for that is the same as for recreational. The government taxes it three times and they pile on a final tax called an excise tax, which no other medication in this country experiences, if it's called medical. I've gone to a lot of the production facilities and a lot of them are legitimately producing medical product, but the recreational side is so attractive financially that most of them are going both routes. It's based on shareholder value in the company, so it's profit that they're after.
That said, there are some companies that are doing their due diligence on the medical side. Should medical marijuana be taxed the same as recreational marijuana, with the additional excise tax or what a lot of people call the sin tax? Should veterans be paying an additional excise tax on what is quoted as being medical cannabis?
Conservative
Phil McColeman Conservative Brantford—Brant, ON
I'll leave it there.
I'll tell you what. Because you can't adequately answer this in 30 seconds and I do need to take care of this business, if I've planted a seed in your brain, maybe you could come back to the answer or one of my colleagues can follow up with you as you think about how you might answer that.
Chair, thank you for giving me notice. I'm sorry that I had to give that much of a soapbox perspective on things.
Chair, I need to put on the table something that's on notice of motion, something that I think has been botched by our committee, if I might take that perspective. That is the fact that with all that's going on, with the chaos in the government today on all that's going on with SNC-Lavalin, we had a minister who resigned from this ministry.
Prior to that, we had a minister. Then Madam Jody Wilson-Raybould came into the position and resigned from her position. Then we had a temporary minister, Mr. Sajjan, who is also the Minister of National Defence. Now we finally have a permanent minister, but there was this whole transition and the ongoing chaos on the government side with SNC-Lavalin and the scandal that involves her testimony to the justice committee. The Prime Minister finally has seen fit to put in a permanent minister.
The reason I'm describing that to you is that this motion deals with that minister coming to this committee to answer the questions around what are called the supplementary estimates (B), the allocation of money for the use of veterans and the payment of money. As a committee, we have a solemn responsibility to make sure that funding goes to the front lines, to where it's most important to veterans. It's intertwined a bit with this, but not a whole lot.
That said, Chair, I'd like to move this motion:
That the committee invite the Minister of Veterans Affairs, the Hon. Lawrence MacAulay, to appear on the Supplementary Estimates (B) on March 20, 2019.
Liberal
The Chair Liberal Neil Ellis
Does anyone wish to speak to the motion?
(Motion agreed to)
Who do we have up next?
Conservative
Conservative
Phil McColeman Conservative Brantford—Brant, ON
Thank you, Chair.
Maybe it's time to ask you to answer the taxation question I had on medical versus recreational cannabis and both being taxed the same with no differentiation. Should medical cannabis be taxed with excise tax?
Mr. Baldwin-Brown.
Co-Founder, Spartan Wellness
As a patient and a veteran, I would have to say no. When you're dealing with veterans who have post-traumatic stress disorder—who make up a large chunk of the medical cannabis patients in Canada—any time you throw a wrench at any type of system, you're going to have issues. Veterans will see any form of unforeseen circumstance or any form of unknown change in a bad light until it's fully explained.
For us as veterans, luckily most of the licensed producers have absorbed that excise tax. However, on the back end, that may not be the best thing for the department. If they're forced to eat one dollar per gram on an $8.50 gram, they may skimp some other procedures or policies in creating the actual cannabis, and we may see a substandard product at the end because of it.
If they are allowed to put that money towards production, paying their people and ensuring it's done properly, with full quality, it wouldn't negatively impact at all. Most producers have been absorbing it.