Okay. Thank you.
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.
4:35 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.
March 20th, 2019 / 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.
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
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.
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.
Liberal
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.
