Ms. Blaney.
Evidence of meeting #112 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 evidence.
A recording is available from Parliament.
Evidence of meeting #112 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 evidence.
A recording is available from Parliament.
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
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
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
March 20th, 2019 / 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.
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.