Veterans Affairs Committee on March 20th, 2019

Yes. I'm in practice in Colorado.

4 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

So you've come in from Colorado. Thank you so much for doing that.

4 p.m.

Physician, As an Individual

It's a pleasure.

4 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

When it comes to the distinction between medical cannabis and recreational product, I believe I've heard, and I'd just like to confirm it, that you both believe there is truly a category called “medical” and that everything outside of that category would be recreational product. Is that correct? I'm not talking about the product specifically, but you talk about medical cannabis, and the fact that it is a medicine. Is that your view, that it is a medicine?

4 p.m.

Physician, As an Individual

Yes. It is clearly a medicine. Cannabis itself can be used in a variety of different ways. When it is formulated as a medical product, to be used for a medical indication, it is clearly a medical product.

It does have recreational uses, historically as well as currently. I think, historically, many people who were using cannabis recreationally were actually treating some underlying medical problem that they may well not have been aware of.

4 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

Thank you for that.

Dr. Waisglass, would you confirm that it is a medicine?

4 p.m.

Medical Director, Canadian Cannabis Clinics

Cannabis can be used as a medicine, and it can be used for the purpose of leaving our current state of consciousness—our present mindset, if you like. It can be used as a euphoriant, to make people feel happier. So it clearly can be used for people to relax in a social setting. These are some of the ways it's used, as you and I would say, probably not as a medicine.

But Dr. Shackelford is quite correct. People will often say they are using it recreationally, but clearly they're using it for pathological conditions like anxiety disorders.

4 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

Of course, we're talking about it in the context of veterans, and I want to keep it in that context, if at all possible.

Are there any other types of medicine, other than cannabis, that people smoke?

4 p.m.

Medical Director, Canadian Cannabis Clinics

Are you addressing me on that one?

4 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

Yes. I'll go to you, doctor. I'd like opinions from both of you.

4 p.m.

Medical Director, Canadian Cannabis Clinics

Okay.

Cannabis is a botanical. It's not a single molecule, which is what we're used to. When we talk about medicine, in the context that I think you're talking about, in the medical and pharmaceutical milieu—now, for almost 100 years or thereabouts—medicine is often thought of as a single-molecule medicine that's usually rigorously screened and checked for indications and risks and so on, and then the doctor, the medic, prescribes it to the patient.

Here we have something different. It requires a bit of a paradigm shift, when traditional medical people and citizens alike look at cannabis in the context of a medicine. It's a botanical. The right person to put this question to would be, say, a naturopath—somebody who deals with botanicals—or an Ayurvedic doctor in India who deals with plants as medicines.

4:05 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

I have limited time, so I have to move quickly. If you could keep your answer brief, Dr. Shackelford, that would be appreciated.

4:05 p.m.

Physician, As an Individual

I think it has been traditional for people to smoke cannabis for recreational as well as medical purposes, but I don't think that's the only way to use it, nor do I think it's the most effective way to use it. There are ingested cannabis-derived products—pills and other forms—that are more medically appropriate and that I think should be at the forefront. I think the state of development up to this point has limited its uses to the kind of traditional inhaled methods, and there are certain indications for those, such as acute nausea in a patient undergoing chemotherapy. But there are more refined types of products available to address that specific need, such as an extracted oil that can be vaporized in a device made for that purpose.

4:05 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

I have one minute left, gentlemen.

I'm going to finish up on one last question, which is this. In this country, there is no distinction between medical and recreational cannabis in terms of how the government is employing the taxation regime. All other pharmaceuticals and medicines in this country are not taxed if they are considered medicine. In this country, we are applying what's called an excise tax, which many people know as the sin tax, the same one that's on alcohol and cigarettes, tobacco products. It's added onto two other taxes, both provincial and federal taxes, plus the final tax on a tax.

Do you agree or disagree that medical cannabis should be taxed with that additional sin tax, that excise tax?

We'll go to Dr. Waisglass in Toronto.

4:05 p.m.

Medical Director, Canadian Cannabis Clinics

I couldn't be more disturbed by this government's decision to burden medical patients with this additional tax. Skirting that particular item, in my talk I pointed out that the people most in need and the people who most benefit from medical cannabis are often those who are suffering the most financially in their lives, and who are unable to work and unable to participate in society.

So, I'm with you. It sounds like your inference is that this is a horrible thing and mean-spirited as well, and they have to rescind that tax.

4:05 p.m.

Liberal

The Chair Liberal Neil Ellis

Dr. Shackelford, if you want to answer, we can give you some time.

4:05 p.m.

Physician, As an Individual

Other jurisdictions, such as Colorado, make a very clear distinction between recreational cannabis and medical cannabis, and both products are taxed entirely differently. I think that taxing the medical applications, the medical uses of cannabis as a recreational product is incorrect.

4:05 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

Thank you.

4:05 p.m.

Liberal

The Chair Liberal Neil Ellis

Mr. Eyolfson.

4:05 p.m.

Liberal

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

Thank you, Mr. Chair.

Thank you both for coming.

Dr. Waisglass, I noted that in one of your comments you talked about.... I wasn't at the previous meeting, but you were referring to the previous witnesses in medical research and clinicians as being, in your words, “entrenched” in the medical system and over-exaggerating the harms and underestimating the benefit.

Full disclosure: I'm a physician. I also spent five years doing medical research before I was in medical school.

When you look at the levels of evidence that we have to have.... For instance, if there's a new blood pressure drug, you have your basic science research. You then have your animal trials. You have your human trials. You have your gold standard, the randomized clinical trials. Given the backgrounds of people, with these different methods, what evidence is there to counteract what they're saying from their knowledge and experience? What is the level of evidence to say that, no, these high doses are not harmful, or to say that these benefits are there, when others who are performing medical research in clinical medicine don't agree?

4:10 p.m.

Medical Director, Canadian Cannabis Clinics

If the measuring stick is going to be the same for a botanical as for a single-molecule pharmaceutical drug, we have problems. That's one of the reasons for the delay in getting the evidence we need.

There are two reasons why we do those studies. One is to convince Health Canada, or whoever's going to determine that a new product can come onto the market, that the drug is efficacious—it's going to work for that problem better than a placebo will. Two is that it's safe. Is that not correct?

4:10 p.m.

Liberal

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

That's correct.

4:10 p.m.

Medical Director, Canadian Cannabis Clinics

We want to know its safety. We want to know it's not going to kill people or give them cancer.

With medical cannabis, we need to be more patient, because it's very difficult to assess it in the same way. My answer to you is that there is ample preclinical science to make us believe.... There are thousands of studies on animals, and cellular and biological sciences, molecular studies and so on to tell us that cannabis is safe. We have historical evidence that tells us it's safe. It was used as a medicine for hundreds of years throughout Europe and North America and other parts of the world as a drug much as we know it, only in tincture form.

Currently, we have observational studies. We have a variety of smaller studies. New ones are under way, and you can get preliminary reports on those that tell you both that cannabis has relatively few serious side effects, which are easily managed, and that it is very efficacious, very effective, in a great number of treatments and for symptom relief.

The doctors who speak against it are entirely unfamiliar with the observational studies, or they discredit them quickly. A great deal of the negative papers published on cannabis—I know, because I've been through damn near all of them—are rife with bias. Bias permeates our society—bias around cannabis in particular—which is religious, cultural, political or social. We all know that, and you've probably heard from a number of people, officially and unofficially, who have this bias.

In the same way, there are people with biases in favour of cannabis—cannabis can do no wrong and it fixes everything. We have to discount those people too.

4:10 p.m.

Liberal

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

Thank you.

Dr. Shackelford, do you have anything to add to that?

4:10 p.m.

Physician, As an Individual

I did medical research as an undergraduate medical student at Heidelberg University, and I published five papers—both basic science or animal work and clinical investigations. I was a research fellow at Harvard Medical School in my postgraduate training, which was one of my three fellowships after an internal medicine residency at Harvard. I am extremely familiar with investigations of this nature, and I've been looking into the research evidence that supports the use of cannabis as a treatment.

There are extremely well-done, randomized, placebo-controlled trials, both in Canada and the United States, and in other countries, that support the use of cannabis and its safety and efficacy. One study by Donald Abrams, published in 2011, showed that the use of cannabis—in that particular study it was vaporized—in conjunction with prescription opioid pain medicines allowed a reduction in the dose of the narcotic pain medicines by 25%. In and of itself, that is an important way of decreasing the risk that patients are exposed to in the use of opiates, and the pain control was equally good.

There have been studies in Canada by Dr. Mark Ware, whom you may well know, who showed that inhaled cannabis—smoked, again—was efficacious for the treatment of neuropathic pain.

One of the problems, however, with being able to do these types of studies that we are all familiar with as physicians and scientists is institutional bias—particularly in the United States—against doing studies involving cannabis. There is a very clear disinterest in showing that cannabis may have any medical benefit, and that has limited our ability to carry out appropriate studies. Nonetheless, the study I cited by Dr. Abrams was done with permission by the National Institute on Drug Abuse in the U.S., and there are other studies that are equally demonstrative of benefit.

In terms of risk, other studies have shown poor evidence that using cannabis is linked to any sort of development of psychiatric or physical disease.

4:15 p.m.

Liberal

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

I'm sorry, but could I cut you off there? I think I'm just about out of time.

4:15 p.m.

Liberal

The Chair Liberal Neil Ellis

Yes.

4:15 p.m.

Liberal

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

Sorry about that. Thank you very much.

4:15 p.m.

Liberal

The Chair Liberal Neil Ellis

Ms. Blaney.

4:15 p.m.

Rachel Blaney North Island—Powell River, NDP

Thank you very much, both of you, for being here today.

I'm going to start with you, Dr. Shackelford, if that's okay. One of the things you talked about.... I think it's a complex issue. We're really looking at veterans and their need to get the medicine that's going to make their lives so much better. We know, looking at the multiple challenges—and you outlined them very clearly—that finding something that's going to make life something that they're going to stay with us here for is really important, so I appreciate the work that's been done.

You said in your statement that you saw remarkable responses to medical cannabis. You also mentioned meeting and seeing 30,000 patients. First of all, I want to know if those 30,000 patients were all veterans. Also, could you talk about what that remarkable response is?

One of the things I'm trying to get clearer about is whether it's about matching the right type of cannabis with the right patient. How much work is that? What we have right now is that you're allowed to get three grams, and that's dried. One thing that's happening when they're going out to get it, internally within the clinic they're getting it from or the place they're purchasing it from, is that if they're using something else, they're figuring out what the equivalency is. I'm concerned that this isn't really meeting the needs of our veterans.

4:15 p.m.

Physician, As an Individual

Those are important questions.

The 30,000 were 30,000 individual patient visits over 10 years. Many of them.... I don't have the exact numbers of how many were veterans. Of course, after increasing numbers of service members started coming back from Afghanistan and Iraq, the number of veterans I would see increased. It is probably in the neighbourhood of 10% or something of that nature, maybe fewer.

The types of problems that the service members and the veterans presented with were extraordinarily complex in almost every case. Many had PTSD. Of course, PTSD is not restricted to military service members or people who have seen combat. It also results from automobile accidents or other situations in which the individual feels that his or her life is in danger.

In looking at veterans, however, the number of pharmaceuticals typically being prescribed is six to 10, and the complexity of the issue.... As I said in my statement, it can be physical pain, or it can be PTSD and a variety of other things, including traumatic brain injury, which carries another set of problems. I have seen probably the majority of service members—I'll restrict it to PTSD—being able to stop using their medicines, become productive again and engage with their families. This is not unusual.

In terms of the type of cannabis they would use, first, for three grams, it depends on what the equivalency is. If it's extracted and used in an oil, it's a different product, rather than simply smoking the three grams. I am almost 100% certain that it's an insufficient amount under any circumstances, be it extracted and orally administered or smoked.

I don't think there is any real, clear evidence that one type of cannabis or strain with a particular strain name is necessarily more beneficial. I think it is a question of what the cannabinoid content is and what chemicals are actually involved. CBD, for example, is much more effective as a treatment for anxiety than THC is. The particular diagnosis should dictate the type of treatment that's employed.

4:20 p.m.

North Island—Powell River, NDP

You also mentioned the work that's happening in Israel, I believe, talking about cannabis pharmaceuticals, which might work better. Can you tell me what the difference is? What will work better?

4:20 p.m.

Physician, As an Individual

As Dr. Waisglass said, botanical cannabis is complex. It's a plant. I think it can play a role, but I also think that if we are to call it medical cannabis, it has to be medical cannabis. Now, it doesn't have to be a medical plant. It can be a medical substance, such as an extract in pill form, for example, or a liquid extract that could be used under the tongue as a sublingual. What's really important is the consistency of the extract or the product itself and the known quantity of cannabinoids, be they CBD, THC or any of the others that we know something about, which are CBN, CBC and CBG, of the 110 or so.

We do know from excellent animal work and some human work that the complexity of different cannabinoids in the whole plant extract is more effective than one single compound alone. That was demonstrated in the trials for Epidiolex, a CBD-based anti-epileptic drug recently approved in the U.S. That is what's being looked at in Israel, and hopefully in Canada. I'm very interested in the collaborations that are possible. I'm a member of the Cannabinoid Research Initiative of Saskatchewan, at the University of Saskatchewan, and there are plans to investigate this here in Canada as well.

The intention is to create cannabinoid-based or cannabinoid-derived actual medications that are consistent from dose to dose and product to product so that they can be used as pharmaceuticals. Now, we're not there yet. This doesn't mean that we shouldn't be using cannabis, because there has been demonstrated efficacy in scientific study that goes back to the early months and years of the past century and this century. There's a great deal of evidence for this, and it is safe.

Until we actually have the pharmaceuticals, it doesn't mean that we shouldn't treat people appropriately and with the products that are indicated. It just means that we have a lot of work to do to bring it up to the standards that we all expect.

4:20 p.m.

Liberal

The Chair Liberal Neil Ellis

Thank you.

Mr. Bratina.

4:20 p.m.

Liberal

Bob Bratina Liberal Hamilton East—Stoney Creek, ON

Thank you.

First of all, Dr. Waisglass, I was interested in your comment that some of the prescriptions really didn't seem to work out very well, so you brought in botanicals and other things. The question becomes, how are we medicating?

Could you give me an example of something that would have been prescribed for a situation, a health issue, that didn't work out? Should we be looking at how we're prescribing, if those problems are arising? Did I get you right on that? Some prescriptions for veterans just weren't working out at all, whereas the other modalities were working out, if you follow me.

4:20 p.m.

Medical Director, Canadian Cannabis Clinics

Just so I'm clear about that question, do you mean conventional prescription medication that failed to work well?

4:20 p.m.

Liberal

Bob Bratina Liberal Hamilton East—Stoney Creek, ON

Yes. That's what I gathered from your statement.

4:20 p.m.

Medical Director, Canadian Cannabis Clinics

Yes, I'd be surprised if the room you're sitting in wasn't filled with people who could give me an example of being given a drug, having a side effect from it and not being able to take it. Or maybe it was partially efficacious. That runs across the full gamut of medications we have for all the common diseases, such as hypertension, diabetes, arthritis, asthma—name the disease. There are numbers of people who find the side effects intolerable. They either stop taking their medication or are back at the doctor's office and saying that it isn't working well or it doesn't agree with them because of x, y or z, so another prescription is given.

It's particularly true, as Dr. Shackelford mentioned, about vets—and many non-vets, for that matter—who are on multiple medications with a lot of drug-drug interactions. That's where I was going with this when I mentioned why so many people go to naturopathic, herbal, acupuncture and a whole bunch of other unconventional treatments, if you like—because of the relative failure in being able to fulfill the promises made by pharmaceutical companies and doctors. We're now seeing that alternatives seem to be as important to veterans as they are to the rest of us.

4:25 p.m.

Liberal

Bob Bratina Liberal Hamilton East—Stoney Creek, ON

I wonder if that would be the basis of another study, but we'll leave it at that. I thank you for that answer.

On the question of PTSD, I was born during the Second World War, so I observed what we used to call shell shock. Cars in that era often backfired, and there were veterans on our street, so I get that.

My uncle was on an American aircraft carrier, the Bunker Hill. They took two kamikaze hits, and 600 of the crew of 2,600 were casualties. I can recall that they were trying to identify.... In an incident such as that, there were terrible fires on the hangar deck, so to identify the lost sailors, they basically had to hold up the remains of the person and try to figure out who it might have been, in order to get all of the identities. My uncle had fond memories of being a sailor—not fond memories of that, of course—life on the sea and so on. I know that it would be different for different people, but I never saw any PTSD or a cringing at the memories of his service.

I'm just wondering about it. Was there something different about the World War II experience versus the Vietnam, Afghanistan and Iraq sequence?

4:25 p.m.

Physician, As an Individual

Those were extremely problematic memories, I'm sure, for a great many people who served on the Bunker Hill. There are a lot of instances like that. It's not clear why one individual develops PTSD and another does not, nor is it completely clear exactly how many military members have PTSD. The manifestations can come quickly after a particular incident or not manifest for decades. I don't think there is a significant difference in the military experience, except that probably the likelihood of being helped or having support, or the sense that the mission was worth it, plays a role.

I spoke at some length with a Canadian Army officer who had been in Rwanda some years ago. He had very explicit PTSD. It was extraordinarily difficult for him, but buddies of his who were in the same unit, in exactly the same settings, had no such problem. I think that if we could identify what it is that makes one service member more resilient compared to another, we'd be well served.

However, I do think that pre-treatment with cannabinoids.... There is some evidence that this may be beneficial. Pre-treatment with cannabidiol or possibly some combination of CBD and THC may be beneficial in preventing the neurological sequence of events that results in PTSD. We don't really know yet.

4:30 p.m.

Liberal

Bob Bratina Liberal Hamilton East—Stoney Creek, ON

Do I have any time left? No?

Thank you.

4:30 p.m.

Karen Ludwig New Brunswick Southwest, Lib.

Thanks to both of you for your presentations today. I actually had the same questions for both of you. I'll start with Dr. Shackelford.

We heard a recommendation earlier this week for a tailored educational program for military families. Can you offer some recommendations for what that might look like?

4:30 p.m.

Physician, As an Individual

Can you clarify just a bit, please? Is it a tailored program for military families with regard to the use of cannabis?

4:30 p.m.

New Brunswick Southwest, Lib.

Yes, that's right.

4:30 p.m.

Physician, As an Individual

Well, I think we have to start with the notion that cannabis, when properly used, is a medical intervention. As with every medical intervention, whatever therapeutic substance is being used should be kept isolated and away from children, for example.

I don't know that there really is a necessity to have a specific and special educational program for families that are using cannabis over families whose members are using other prescription drugs. I think all of the same cautionary measures apply, with one important distinction, and that is that if a child gets into the cannabis, that child is not going to potentially die. There is no known lethal dose of cannabis, which is not true for the prescription medications that are often in use in the treatment of PTSD or any other medical problem. All of those cautions apply. The side effects of indulgence, overindulgence or misuse can be problematic and may require medical intervention; they just don't require life-saving medical intervention.

I think a military family should be informed to keep the medicines sequestered under lock and key and not available in any fashion to children, and to use them as prescribed or as directed, as opposed to self-medicating. That's an extraordinarily important point. The physician who is administering or authorizing the use of cannabis—because that's what we're talking about—or of any drug has the obligation of informing the patient of expected use and that there is an expectation that those parameters will not be violated.

Simply turning someone over and saying that they can have 10 grams of cannabis and go and use it in any way they want.... I don't think that's appropriate. I think the physician should instruct the patient in proper use and proper dosing and follow up with that patient regularly so that the efficacy and the proper use can be ascertained.

4:30 p.m.

New Brunswick Southwest, Lib.

Before I switch to our other witness, could I just add to that or extend that question? We've heard from a number of witnesses before this committee that the average duration of medical training regarding prescribing or approving cannabis is about an hour and a half at a medical school. There seems to be an awful lot of information to be learned.

Do you ever have an opportunity to go in as a guest speaker to medical programs, nursing programs or graduate programs for nurse practitioners?

4:30 p.m.

Physician, As an Individual

I do. I spoke to the medical faculty and the student body of the university of Uruguay a couple of years ago for precisely that reason. I think we do need to have coursework for undergraduate medical students—but also in postgraduate training for residencies—that involves the proper use of cannabinoid medications. I think we should look into creating a training program for physicians, both civilian and military, for the proper administration of cannabinoid treatments.

4:30 p.m.

New Brunswick Southwest, Lib.

Thank you.

Do I have any time left? Okay.

I'd like to ask Dr. Waisglass the same questions.

4:30 p.m.

Medical Director, Canadian Cannabis Clinics

I'll start with the last one first. Medical education for medical students, nursing students and anyone in the health professions is clearly important. Looking over—

4:30 p.m.

New Brunswick Southwest, Lib.

What about those who have been in the profession for 15 or 20 years? Do they continually go back for...? I would call it upgrading, but I'm sure it's just further training.

4:30 p.m.

Medical Director, Canadian Cannabis Clinics

There are many parts to your question.

All of our colleges here in Canada require doctors to keep up. Those requirements are dictated by each province or territory, as you know. Each of the colleges dictates for the specialists and for the family doctors, the non-specialists, what the requirements are for them in the way of keeping continuing medical education up to date. There are ways to skirt it. Not everybody does it, but these colleges do police it. Specifically—

4:35 p.m.

New Brunswick Southwest, Lib.

I'm sorry. I have one more question on that before you go any further. Is every province consistent with the others in terms of keeping doctors current on illnesses?

4:35 p.m.

Medical Director, Canadian Cannabis Clinics

[Technical difficulty—Editor] consistent province to province or territory about anything to do with health care. Each province tweaks it and makes it just a little bit their own. It applies to cannabis as well.

4:35 p.m.

New Brunswick Southwest, Lib.

Okay. Thank you.

4:35 p.m.

Medical Director, Canadian Cannabis Clinics

The education is hugely important, as a previous speaker suggested. What happens for anybody in this industry, the medical industry itself, is “see one, do one, teach one”. I was the founding member of Canadian Cannabis Clinics. The next doctor to come along who wanted to work with me, or in one of our adjoining clinics or nearby clinics, I trained. I made recommendations about how they could get the rest of the training they needed. The training of doctors for medical cannabis is not happening in medical schools, you're quite right. They might learn about it as a botanical for an hour, but the teaching of treatment with botanicals is not part of our curriculum anywhere that I know of, other than India.

As for your question about the cannabis education program for military families, my initial reaction was like Dr. Shackelford's: Why are we doing this? What's the purpose of it? But I had a few more seconds than he did to think about it a little bit, and perhaps one of the thoughts behind this—again, I'd just be guessing—would be the same thing that many doctors do when they treat someone with any mental health issue. That is, they get a loved one into the office with them for all visits, because for any treatment employed, cannabis or otherwise, it's important for the loved one, the person in the household, to know about it.

I hate to take more time when you're all so strapped for it, but I would add that this was a really important thing I brought into my cannabis practice too. In a first follow-up visit, let's say, I would ask the patient, “What happened when you used the cannabis? How was your pain?” They'd say, “It was the same, Doc. It didn't work.” When I'd ask them how their sleep was, or their mood, they'd tell me that it didn't do anything. Then I'd look over at the spouse, and the spouse would be smiling.

So I would address the spouse about their husband or wife, or whatever the case was, and say, “They didn't seem to have a very good response, but your face kind of belies that. What's going on?” I would hear things like, “She's now back to doing the laundry; I don't have to do it anymore” or “He's down in the workroom. He hasn't been down in the workroom in two years. He's back doing his woodworking again.” I can't tell you how many times I had something like that happen.

People are expecting from cannabis medicine something just a little bit different. If you teach the most significant other in the family about it, that is pretty important, as is telling them the facts about cannabis and rolling out the truth about its risks and benefits. For instance, people don't have to be afraid of second-hand smoke. They won't go crazy or psychotic. A lot of people have sucked in a lot of the nonsense about cannabis—the lies, the exaggerations, the hazards. It wasn't very long ago that officials were saying that if you smoked cannabis, that was a gateway drug to mainlining speed or something else.

4:35 p.m.

Liberal

The Chair Liberal Neil Ellis

Thank you. We're out of time.

Mr. Kitchen.

4:35 p.m.

Conservative

Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK

Thank you, Mr. Chair.

Doctors, thank you both for being here today. I greatly appreciate your testimony.

I thank my colleague Ms. Ludwig for her previous question, because she took one off my list. This was specifically the question dealing with training and how we have very limited training for our physicians in dealing with a broad subject like this.

One thing that spurred me to actually put forward the motion for this study was partly what I heard from the two of you today. It was when we were doing a study on mefloquine. We were listening to veterans, plus their family members, give testimony about how impactful it was for them and how they got their spouses back when some of them started taking marijuana and getting off their medications. It was great to hear your comments on that and on how we see that evidence.

The problem we have here as a committee is that when we look at things...and I look at it from a scientific point of view. When we look at the hierarchy of evidence, anecdotal evidence, as you're well aware, is at the bottom of that pyramid. It's a big challenge when we're sitting here looking at anecdotal evidence. In the past, when we've done studies, we have not accepted anecdotal evidence as a justification for making our recommendations. We have a history of that. So how can we turn around here at committee today, listen to what we're hearing on anecdotal evidence, and say that this is a good thing? Although what we're hearing sounds great, it would be hypocritical of us to say that we will deny anecdotal evidence on mefloquine and yet will accept it on marijuana.

I would like to hear your comments on that, please, starting with Dr. Shackelford.

4:40 p.m.

Physician, As an Individual

I think those are important considerations. I think they perhaps should serve to prompt us to do more investigations. On the other hand, as Dr. Waisglass said, a great many studies have been done on cannabis as a medical treatment option. I think we can draw on that body of objective evidence to justify, I would suggest, authorizing the use of cannabis as a treatment option for veterans. I think that body of evidence supports its use. I would be happy to provide—I'm sure Dr. Waisglass would as well—a list of scientific references to these studies. I have been reading these over at least the last 10 years. The committee and anyone else would be able to reference those studies as a basis for advancing the use of cannabis as a treatment.

I don't think there's a paucity of evidence at all. I do think that a great deal of it is anecdotal, but that doesn't mean there aren't objective, well-done studies that support its use.

4:40 p.m.

Conservative

Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK

Dr. Waisglass.

4:40 p.m.

Medical Director, Canadian Cannabis Clinics

I don't think it's a case of choosing to endorse medical cannabis for veterans or not recommending it at all because all we have is anecdotal evidence. There are massive amounts of anecdotal stories out there, but that's not what your committee needs to look at. You need to look at good-quality observational studies that are quite legitimate.

As Dr. Shackelford says, you don't need to be a scientist and you don't need to go onto Medline and do your search. You can go on a simple website like projectcbd.org and probably get all the information you need about medical cannabis as a legitimate treatment for a whole number of different conditions. There are some very reasonably done observational studies that unquestionably are acceptable guidelines for physicians and for bureaucrats as well to be able to make judgments about the patients/citizens they have to look out for.

I don't think it's an issue that you don't have enough evidence. There is enough. When looking at evidence, though, one needs to be extremely critical. Sometimes that takes some training. I looked at a PTSD and veterans study today that somebody sent me. It was just a lot of garbage. It was a highly biased mix-up of information, confusing medical cannabis with recreational cannabis, meaning high-THC cannabis—who knows what the person was getting—versus medically prescribed cannabis with CBD in it, which is so much safer. It was mixing up nabilone and other prescription pseudo-cannabis drugs or cannabinoid prescription drugs and cannabis itself.

If you look at who is writing it and who is funding the study, you can tease these things apart. That's what I did before I decided to do this full time. You could commit yourself to the same, if you wanted to.

4:45 p.m.

Conservative

Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK

Right, and I appreciate that. I understand, as you will understand, that.... I get it that we have observational evidence. The problem we have with observational evidence, compared with randomized controlled trials, is that, number one, the risk of bias is much higher. As well, the quality of evidence is much lower. You have those challenges when you're trying to do that. I agree with you about the aspect of looking at who wrote the paper and what biases they might have. They might be affiliated with some organization.

At any rate, I want to go on a little bit, if I can. I appreciate your comments on that.

4:45 p.m.

Medical Director, Canadian Cannabis Clinics

Perhaps you will allow me to add just one more thing.

4:45 p.m.

Conservative

Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK

Sure. Just make it quick.

4:45 p.m.

Medical Director, Canadian Cannabis Clinics

When you're doing this, you have to keep in mind that cannabis is a botanical. It's a herb. It's not the same. It's very difficult, when you're assessing the science on it, to consider that. If you want to look at what cannabis will do, look at the pharmaceutical products that have evolved from cannabis, or that are pure extracts, such as nabiximols, and look at the science on that. It's rock-solid.

4:45 p.m.

Conservative

Robert Gordon Kitchen Conservative Souris—Moose Mountain, SK

Aspirin came from tree bark, so it's a botanical as well.

4:45 p.m.

Medical Director, Canadian Cannabis Clinics

Yes.

4:45 p.m.

Liberal

The Chair Liberal Neil Ellis

Mr. Samson, you have six minutes.

4:45 p.m.

Liberal

Darrell Samson Liberal Sackville—Preston—Chezzetcook, NS

Thanks to both of you for your presentations and the information you've provided thus far.

Dr. Shackelford, you mentioned that you noticed a big difference. Once individuals, veterans or others, use cannabis, there's a drop in other medications, quite significantly with opioids and others. Is that correct?

4:45 p.m.

Physician, As an Individual

That's correct.

4:45 p.m.

Liberal

Darrell Samson Liberal Sackville—Preston—Chezzetcook, NS

Would you agree with that, Dr. Waisglass?

4:45 p.m.

Medical Director, Canadian Cannabis Clinics

Absolutely.

4:45 p.m.

Liberal

Darrell Samson Liberal Sackville—Preston—Chezzetcook, NS

We're seeing unconventional methods—you talked about being in the conventional doctor role for 30 to 40 years and now being involved in the unconventionals—things that were being used when you were practising or shortly thereafter. Are you noticing less usage of those and more movement towards medical cannabis? In other words, are they substituting this new unconventional, if you like, for other unconventionals?

4:45 p.m.

Medical Director, Canadian Cannabis Clinics

I don't have the data on that, but I can tell you that there is evidence out there—particularly from the state where Dr. Shackelford is working and some other jurisdictions—good papers reporting on the reduction of pharmaceutical sales and presumably the use of pharmaceutical products in jurisdictions where the state moved to legalizing medical cannabis. In other words, there's evidence that people, when using cannabis, will stop using their prescription hypnotics, sedatives, painkillers and the like.

4:45 p.m.

Liberal

Darrell Samson Liberal Sackville—Preston—Chezzetcook, NS

Do you want to add to that, Dr. Shackelford?

4:45 p.m.

Physician, As an Individual

Yes, thank you. This is an extremely important point. There are two papers, specifically one from Health Affairs from 2016 and one in the Journal of the American Medical Association, also from 2016, I think, which showed a very distinct decrease in the number of prescription pills issued per physician in U.S. states that have medical cannabis programs. The number of opioid prescriptions per physician dropped by 1,800 in the states that enacted medical cannabis programs. The result of that is what was reflected in the JAMA paper, which was that there were 25% fewer unintentional opioid overdose deaths in states that had enacted medical cannabis programs, compared to the number in states that had not enacted cannabis programs.

The decrease in the number of prescriptions per physician was reflected in a significant drop in the number of unintended deaths from opioid overdose. That is a huge problem in the U.S. In 2017, I think 72,000 people died from unintended opioid overdoses and drug interactions. Something as simple as aspirin or non-steroidal drugs—indometacin of course being a prescription drug and quite an aggressive one—kill about 15,000 to 20,000 people in the U.S. We think of these things as being innocuous, and yet they are not. This is most important.

4:50 p.m.

Liberal

Darrell Samson Liberal Sackville—Preston—Chezzetcook, NS

My colleague asked earlier about the right cannabis for the right person or the challenge they're faced with. If I were to ask each of you individually in a separate room the three main areas or causes that medical cannabis is helping with, could you zero in on those? For example, we're seeing PTSD. What are the three main areas that you feel medical cannabis is helping patients with? Think about it for a second, and hold on to those three, and we'll take a response as we move forward.

Dr. Shackelford, you can go first.

4:50 p.m.

Physician, As an Individual

There's PTSD, of course. I see a lot of veterans, and they refer their veteran friends to me, but 93% of the 88,000 or so patients who now have medical cannabis cards in Colorado use it for pain. One reason is that we don't have very good treatments for pain, and many of them are fraught with danger, as is the case with opioids. I've seen significant improvement in pain.

Muscle spasms are also one of the approved conditions. Interestingly, it's not an approved condition in Colorado, although it is in other states. The U.S. has a mishmash of different approved conditions. In the case of autism, there's a study from Israel that shows that cannabis is effective in assisting autistic children, some profoundly autistic. I have seen a few patients with autism who have responded extraordinarily well.

Seizure disorders are particularly responsive to cannabis. It's most interesting that Epidiolex, the most recently approved single-compound CBD drug for the treatment of seizures in Dravet syndrome specifically, was effective in fewer than about 43% of the patients and did nothing at all for nonconvulsive seizures, and yet it was approved as a pharmaceutical prescription drug in the U.S. when its efficacy is not particularly good. Whole-plant cannabis is much more effective for treatment of seizures.

4:50 p.m.

Liberal

Darrell Samson Liberal Sackville—Preston—Chezzetcook, NS

Thank you. I think you added a few.

That puts a little more stress on you, Dr. Waisglass, but go for it. It's your call.

4:50 p.m.

Medical Director, Canadian Cannabis Clinics

Which responds better depends on what study you look at, and I don't think it's important. Whether it's PTSD or chronic pain or anxiety or insomnia, cannabis works for all of those different problems.

What I would like to address is the other part of your question, about the specificity or the matching. One of your colleagues asked that too but didn't get my answer. There's a great deal of scientific activity right across the planet. In Canada alone, we have over 50 different academic centres that are studying something about cannabis, from plant science right through to clinical trials on humans using cannabis products. In our company alone, we have just under 50 scientists employed by Aurora, and we're working collaboratively with scientists all over the planet.

Let me tell you, there's a tsunami of scientific activities going on, no question about it, because all the preliminary results are very exciting. What all the scientists are working on, at different levels, is which particular cannabinoids, combined with what other cannabinoids or working individually, have an effect. We know that the terpenoids and probably the flavonoids in the cannabis plant are also contributing.

This information will unfold as the decades unfold ahead of us, but there is no question that nothing will stop this scientific activity from yielding very specific information for us to zero in on some of those particular strains and at the very least be able to match them. We're doing that with observational studies, with patient data, and trying to match. Our counsellors have this information, that certain people with migraines do better with this or that strain.

4:55 p.m.

Liberal

The Chair Liberal Neil Ellis

We're going to have to hold you there. Mr. Samson has run out of time.

4:55 p.m.

Medical Director, Canadian Cannabis Clinics

Okay.

4:55 p.m.

Liberal

The Chair Liberal Neil Ellis

We'll have to switch to Mrs. Wagantall now.

4:55 p.m.

Conservative

Cathay Wagantall Conservative Yorkton—Melville, SK

Thank you.

I appreciate all of your testimony. This issue is very important to me personally in working with our veterans, the question of how and when they should use this particular product.

I want to talk very briefly with you about mefloquine toxicity and whether you've had any involvement with that. It's an issue for all of our allies and for us, in that veterans were given this anti-malaria drug and it has caused issues. We found with many of our veterans that they found cannabis treatment to be very effective, whereas pharmaceuticals just seemed to complicate it because it's a brain stem injury, not PTSD, which it's often considered to be. Have you worked with any veterans who are suffering from this particular condition?

4:55 p.m.

Physician, As an Individual

I have not. I'm not familiar with the clinical presentation of it. Perhaps Dr. Waisglass can comment more on that. I have worked with veterans from the U.S. military forces who were given anthrax vaccine and had some significant reactions to that. A lot of them involved chronic pain. I haven't seen as many of those veterans as veterans who have PTSD, but those with pain from the anthrax vaccine, which included a lot of muscle spasms, responded quite well to cannabis.

4:55 p.m.

Conservative

Cathay Wagantall Conservative Yorkton—Melville, SK

Dr. Waisglass, have you worked at all with any mefloquine toxicity issues?

4:55 p.m.

Medical Director, Canadian Cannabis Clinics

I have not.

4:55 p.m.

Conservative

Cathay Wagantall Conservative Yorkton—Melville, SK

Okay. I just wanted to follow that up.

When it comes to the research that's going on and the discussion around its needing to be done, I was very pleased to hear, Dr. Shackelford, that you mentioned working with the University of Saskatchewan. I'm from Saskatchewan, and I'm very proud of our university. Along with the University of Regina, they're doing a great deal of work on service dogs and on a new study that is happening right now with regard to mefloquine.

I would be curious to know exactly what your involvement is and what they are working on. How important is that collaboration around the world in coming up with some of the answers we need, without all of us trying to do it on our own?

4:55 p.m.

Physician, As an Individual

It's extraordinarily important. CRIS, the Cannabinoid Research Initiative of Saskatchewan, is a couple of years old now. A symposium was held in August, at which I spoke. The basic science research that's being done in Saskatchewan, specifically in this program, is really extraordinary. A group was brought in from the Max Planck Institute in Germany. A Canadian—from Saskatoon, actually—who had been working there brought his entire team of 20 different researchers to Saskatoon to work on cannabis plant research. The professors are extraordinarily well trained.

There's a spirit of collaboration in cannabinoid research that is unusual, certainly in my experience, compared to other research initiatives. If we look at the collaboration or, if nothing else, simply at the communication among research institutions all around the world, be it in Israel, the U.S. or here in Canada, or even in places as diverse as the South American countries of Colombia and Uruguay, as Dr. Waisglass said, this is an area of inquiry that is absolutely moving forward at a breakneck pace. Innovations are going to be forthcoming that will be really quite remarkable.

4:55 p.m.

Conservative

Cathay Wagantall Conservative Yorkton—Melville, SK

Dr. Waisglass.

4:55 p.m.

Medical Director, Canadian Cannabis Clinics

I'm sorry, but because of volume issues I was unable to hear the first part of your question.

4:55 p.m.

Conservative

Cathay Wagantall Conservative Yorkton—Melville, SK

I was asking for feedback on the involvement of other universities or organizations working on research. Specifically for me, the University of Saskatchewan in our province, a province of a million people plus a few, is doing phenomenal work in this area. I wondered if you had any collaboration or experience with studies and whatnot that those organizations have done or are working with.

5 p.m.

Medical Director, Canadian Cannabis Clinics

Aurora has several properties. One of them is CanniMed, which was the first of the licensed commercial producers. CanniMed is in our fold, so we work with the science people in that area too. Yes, we are collaborating with university centres and research centres in a number of provinces. I don't even have all of their addresses: the University of Alberta, UBC, the University of Toronto, McGill....

5 p.m.

Conservative

Cathay Wagantall Conservative Yorkton—Melville, SK

Okay. That's great. Thank you.

Dr. Shackelford, our committee did a trip down to Washington, and we got to go to the Walter Reed hospital there. In one wing, if I remember correctly—you guys may correct me—they were working with patients who had severe trauma and were on strong pain treatment.

The goal there was to help them get to where they no longer had to have that level of pharmaceuticals, because obviously there are reactions. Are you aware whether in the States cannabis is being used in part of that process where you have those traumatic injuries and you need to get these individuals to where they can either go back and serve or join civilian life or whatever? Is it part of that process?

5 p.m.

Physician, As an Individual

It's not, in the U.S., as cannabis is considered to have no medical benefit or uses and a high abuse potential by the U.S. government. That's not to say that there's not a lot of interest, but the constraints that are placed on the veterans administration and the military establishment are so significant that nothing can be done, even though there is a great deal of interest.

Now, the veterans administration does not prohibit veterans from using cannabis medically in states where it's legal to do so, but neither the VA nor the defence department has an official program. I'll be frank. I think the United States can learn a great deal from Canada, not only in this regard, but in other ways as well, and certainly in this particular instance.

There is an opportunity here for Canada and Veterans Affairs to be pioneers, I think, in making a treatment available, as crude as it may now be, but also in investigating it and in setting up, as I've suggested, training programs for physicians, and possibly research programs that could be done in conjunction with the defence department or—

5 p.m.

Conservative

Cathay Wagantall Conservative Yorkton—Melville, SK

Well, we're in a state of flux as well, because right now our treatment centres that veterans can go to do not allow them to come if they are using cannabis, so we have work to do there as well.

5 p.m.

Physician, As an Individual

Indeed.

5 p.m.

Liberal

The Chair Liberal Neil Ellis

Thank you.

We'll end with Ms. Blaney.

5 p.m.

North Island—Powell River, NDP

Thank you very much, Chair.

I want to get one thing clear. I've heard from both your testimonies that when veterans start using cannabis they are often able to go off many pharmaceuticals that have multiple impacts on their well-being. Is there research specifically on veterans moving off pharmaceuticals and moving toward cannabis and using that successfully? Also, are they tracking them over a period of time?

Could I start with you, Mr. Waisglass?

5 p.m.

Medical Director, Canadian Cannabis Clinics

We're not doing that. I specifically asked the people in our companies about tracking that information. It's not being done. It would be far better to construct a specific study in that regard to gather that information. I don't know of anybody who is doing that, but it has value. Everybody I've talked to has said that it would be valuable information.

I agree with you, but it's not being done.

5 p.m.

North Island—Powell River, NDP

Thank you so much.

Dr. Shackelford.

5 p.m.

Physician, As an Individual

There is nothing in an official capacity in the U.S., but four years ago, the State of Colorado approved a bit over $2 million for a study of veterans and PTSD, using various cannabis profile plants. That study has completed most of its data-gathering.

We don't have enough information. Actually, I have very little that I can quote, but there is a study that is about to be completed on the treatment of PTSD with cannabis in the U.S. It's not official, however. This is one that we paid for from the state with state funds, but it is not a U.S. government-sanctioned study.

Israel is doing studies on the use of cannabis in veterans. One study in particular looked at therapeutic horseback riding, interestingly, with great benefit. They found that service members, veterans, who were engaged in horseback riding under a specific program and using cannabis were much more effectively combatting PTSD than those who were doing one or the other. The administrator of that program said that she had treated about 60 veterans as part of it and there had been no suicides, which is remarkable. Suicide is unfortunately the primary cause of death among Israeli soldiers.

5:05 p.m.

North Island—Powell River, NDP

Thank you.

I believe that's my time.

5:05 p.m.

Liberal

The Chair Liberal Neil Ellis

Yes.

We have a couple of housekeeping items. The analyst has asked for any scientific studies you've quoted and have. Could you send those to the clerk?

5:05 p.m.

Physician, As an Individual

Absolutely, yes.

5:05 p.m.

Liberal

The Chair Liberal Neil Ellis

Also, if there is anything that we didn't have time to cover and that you want to offer in a brief, you could submit that to the clerk. He'll get it to us.

That ends today's testimony.

Mr. McColeman.

5:05 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

Mr. Chair, we have time left, and there are some follow-up questions.

5:05 p.m.

Liberal

The Chair Liberal Neil Ellis

We could run some two- or three-minute rounds, if you wish.

5:05 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

I have just one thing on my mind that I'd like to ask while we have the witnesses.

5:05 p.m.

Liberal

The Chair Liberal Neil Ellis

Anybody else? Mr. Casey, okay.

I see unanimous consent on that, so that's fine.

We'll start with Mr. McColeman. We'll give you three minutes.

5:05 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

I'm wondering if you could do one basic thing for us. You've obviously worked with a lot of veterans. You've seen some successes and you've seen sometimes things not working. Could you give us one of each in just a very brief case-study fashion, if it's possible to do that in the short period of time we have here? Or you can just choose to do one that you think was very interesting, which involved a veteran, and tell us what the result was.

Could I ask that of each of you? Dr. Shackelford, why don't you go first?

5:05 p.m.

Physician, As an Individual

Last week, I saw a young woman who has been a patient of mine for four years, I would say, a service veteran with severe PTSD. She was taking, I think, seven different prescription drugs at the beginning of the cannabis intervention. As of last week, she had not taken any prescription drugs for about three years and is happily employed, now married and with no symptoms of PTSD whatsoever.

A man with extremely grievous combat wounds and PTSD continued to have quite severe pain from the wounds. His PTSD symptoms improved, but I was not as successful at treating the pain with cannabis interventions alone, as I would have preferred. He's on a low dose of narcotics, which in combination with the cannabis is more effective than were the narcotics by themselves, but it was not a full success.

5:05 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

Okay.

Dr. Waisglass.

5:05 p.m.

Medical Director, Canadian Cannabis Clinics

I don't have on the tip of my tongue case studies that would be like a testimonial to say this one worked and this one didn't work. There was no consistency in my experience of seeing veterans or anyone else with PTSD in terms of the drugs that worked or didn't work. I'm referring to cannabis drugs. There are wonderful stories I could tell you, but I would have to prepare for them. I wasn't prepared to give you case studies. I'm not seeing patients anymore. My work involves domestic and international setting up of clinics to give access to people who want cannabis medicine and to show the models that we have that will work in their country—

5:10 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

Can I cut you off there? I have only a couple of seconds.

5:10 p.m.

Medical Director, Canadian Cannabis Clinics

Sure.

5:10 p.m.

Conservative

Phil McColeman Conservative Brantford—Brant, ON

I have one last question, which is about the ratio of THC to CBD oil. Let's take an oil product. How high do you go with the THC component? Will you go as high as required, or are there limitations on the hallucinogenic component that you're prepared to go to? I know many oils are of various ratios and many people experiment with different ratios to find what works for them, particularly in the veterans community. Do you have any comments on the range of each of the two major elements that we discuss when we're discussing this topic?

5:10 p.m.

Liberal

The Chair Liberal Neil Ellis

We're out of time.

Dr. Shackelford, could you answer that quickly?

5:10 p.m.

Physician, As an Individual

I have a child patient with a seizure disorder who takes 250 milligrams of THC a day with extraordinarily good results and no psycho-activity at all—I think “hallucinogenic” is probably an incorrect term—and others who are doing extremely well with two milligrams of THC and two milligrams of CBD. I think it depends on the individual patient: 250 milligrams of THC is a lot, but it works extremely well for this boy.

5:10 p.m.

Liberal

The Chair Liberal Neil Ellis

Mr. Waisglass, I can give you 10 to 20 seconds to answer that question.

5:10 p.m.

Medical Director, Canadian Cannabis Clinics

I just want to reiterate that THC is not a hallucinogenic, and there is no absolute formula. What is interesting about cannabis is that very small doses can work. We know that the average amount, in data from Israel, the Netherlands, and Canada, is about one milligram, 1.5 milligrams, or 0.67 milligrams in the Dutch study. That's the average amount of dried cannabis per person per day, and yet veterans will often use three milligrams. There are people who use five or 10 milligrams of cannabis.

The individual variance is a very difficult thing, and nobody has ever been able to explain why this is the case. Tolerance is a bit of it. You know the word “tolerance” and what it means: If you get used to something or your system gets used to it, you sometimes need to have more of it.

5:10 p.m.

Liberal

The Chair Liberal Neil Ellis

Thank you.

Mr. Casey, you have three minutes.

5:10 p.m.

Sean Casey Charlottetown, Lib.

Thank you, Mr. Chair.

I'm not a regular member of this committee. In fact, it's been about six years since I was a member. However, I'm quite interested in this discussion, particularly around how medical cannabis has succeeded in allowing patients to take themselves off some other drugs.

Dr. Waisglass, you started to answer a question and were cut off. I want to come back to it, because it's actually the exact opposite of the discussion we're having. It's on this whole idea of cannabis as a gateway drug. During debate in Parliament, we heard it described as such by no fewer than three members of Parliament—Mr. Gourde, Mr. Deltell and Mr. Dreeshen.

To Dr. Waisglass first, and then Dr. Shackelford, what does the literature say with respect to cannabis as a gateway drug? What has been your experience in that regard?

5:10 p.m.

Medical Director, Canadian Cannabis Clinics

Cannabis is not a gateway drug. Anyone who says that is spewing out a lot of nonsense. There isn't a shred of legitimate evidence on the planet to support that. It's just rhetoric left over from the old “drug war” time.

In fact, there is a good paper on that. It isn't at my fingertips right now—it's a pity I didn't have the questions in advance to prepare for that—but there is good evidence that it is not a gateway drug. We'll just leave it at that.

5:10 p.m.

Physician, As an Individual

That is absolutely the case. There is no scientific evidence whatsoever that it is a gateway. The gateway, actually, is the dealer who has something else in that armamentarium, that little bag he carries around, and who says, “By the way, why don't you try this?”

There is no scientific evidence whatsoever that cannabis use in any way induces a desire for, or a need for, advancing to any other drug.

5:10 p.m.

Charlottetown, Lib.

Sean Casey

Thank you.

5:15 p.m.

Liberal

The Chair Liberal Neil Ellis

Thank you.

Ms. Blaney.

5:15 p.m.

North Island—Powell River, NDP

Just quickly, I'm a member of Parliament who represents a more rural and remote community. One of the challenges for the many veterans who come to our region is being able to access cannabis in the way they're hoping to.

Dr. Waisglass, with your multiple clinics across the country in the four provinces you named earlier, are you in any rural and remote communities? Do you have any information about the challenges those particular veterans face?

5:15 p.m.

Medical Director, Canadian Cannabis Clinics

That's a really good question about a really important subject. As you know, access to cannabis is all that's been on my mind for the five years I've been in this. I continue to be asked by countries all over the world about this and about how we can solve this problem.

We can't put clinics everywhere. The remote areas can't have clinics, but that doesn't mean they can't have health care. All over the planet we're using the audiovisual equipment that's available to us and very successfully managing to deliver health care to our north, to our indigenous communities where doctors can't get in, and to where nurse practitioners are scarce. This is how we are reaching those patients who can't go to a medical cannabis doctor in their community.

5:15 p.m.

North Island—Powell River, NDP

Thank you.

That's all.

5:15 p.m.

Liberal

The Chair Liberal Neil Ellis

We'll end with Mr. Bratina.

5:15 p.m.

Liberal

Bob Bratina Liberal Hamilton East—Stoney Creek, ON

Thank you.

Dr. Shackelford, it's well documented that there is extensive drug use, especially from the Vietnam era, among soldiers in the field. Would a clinician be aware, let's say with someone suffering from PTSD, of previous drug use? Would you suspect that there would be any connection between the condition and the issues in the battlefield and taking all sorts of drugs, apparently, according to what I have read?

5:15 p.m.

Physician, As an Individual

In evaluating a new patient, it's always appropriate to find out about any history of any drug use, prescription or otherwise—

5:15 p.m.

Liberal

The Chair Liberal Neil Ellis

I think we have bells.

5:15 p.m.

Liberal

Bob Bratina Liberal Hamilton East—Stoney Creek, ON

Perhaps we could just finish this.

5:15 p.m.

Liberal

The Chair Liberal Neil Ellis

I have to get unanimous consent, I believe, to keep going once the light flashes.

Do we have unanimous consent for one more minute?

5:15 p.m.

Some hon. members

Agreed.

5:15 p.m.

Liberal

The Chair Liberal Neil Ellis

Okay.

Please continue.

5:15 p.m.

Physician, As an Individual

Drug use in the field or otherwise was most likely situational, in most instances. I haven't seen too many Vietnam combat veterans who have continued to use narcotics, heroin or otherwise. It's unusual. I think once other treatments are available to them and they are using other treatments, any of that stops really quite quickly. That's certainly what I've been told. My experience is that people get off that stuff—

5:15 p.m.

Liberal

Bob Bratina Liberal Hamilton East—Stoney Creek, ON

Very quickly, would the use of cannabis with PTSD be episodal, or would it be a regimen of daily use?

5:15 p.m.

Physician, As an Individual