Veterans Affairs Committee on Nov. 20th, 2018

[Dr. Cyd Courchesne]

No. We looked at that, and it's too early to see an effect. We continue to look at that but in these early years, we have not seen a significant decrease in antidepressants, opioids and all those other medications.

[Gord Johns, NDP, Courtenay—Alberni, BC]

If the department hasn't reached any conclusions on this, does it plan to study this?

[Dr. Cyd Courchesne]

We continue to monitor it.

[Gord Johns, NDP, Courtenay—Alberni, BC]

In terms of the backlog for disability benefits, does this affect veterans getting access, potentially, to prescriptions for cannabis?

[Dr. Cyd Courchesne]

I wouldn't be able to answer that question.

[Gord Johns, NDP, Courtenay—Alberni, BC]

Okay.

Thank you, Mr. Chair.

[The Chair, Liberal, Neil Ellis]

Mr. Chen.

[Shaun Chen]

Thank you, Mr. Chair.

I want to thank both doctors for being with us today.

Based on Dr. Courchesne's testimony, it's my understanding that the use of marijuana for medical purposes for veterans is in fact nothing new. In 1999 it became legal to possess medicinal marijuana, and since 2008 VAC has covered the use of medicinal marijuana by veterans.

You mentioned the Auditor General's report on this issue. Fortunately, I sit on the public accounts committee, so I'm quite familiar with the Auditor General's reports.

The Auditor General's report that's been referenced by the doctors today states the following in paragraph 4.44:

While the Department advised us that it covered only the amount of marijuana for medical purposes recommended by the physician or a medical specialist, as outlined in the Regulations, we found that the Department had not established limits on cost or the amount to be covered.

In 2008 there was no limit on the cost of the medicinal marijuana that veterans were using. There were also no specifics provided on how much could be covered. To me, that sounds like there's a lack of a specific framework through which VAC provides benefits to veterans.

Can you tell me what has changed since 2008? Arising out of the Auditor General's report two years ago, what has the department done to contain cost and provide a framework for the benefits that are provided to the veterans?

[Dr. Cyd Courchesne]

I was not there in 2008, but we have no reason to disbelieve the findings of the Auditor General. It's a fact that we had no formal policy framework. I guess it was that one case led to another, and it sort of—

[Dr. Alexandra Heber]

—ballooned.

[Dr. Cyd Courchesne]

Yes.

When the Auditor General made those observations, it was an opportunity for us to go back and look at our processes, put in a policy, and look at what we were paying per gram. This is what triggered several months of consultations. We consulted with medical experts. We consulted with licensed producers. We consulted with veterans and family members. We consulted widely. We did research of literature.

It was a double-pronged process: first, the process for medical, and then the cost, which was done by our colleagues in service delivery by consulting licensed producers. Through negotiating, they came to a fair market value price for cannabis for medical purposes. That's how we landed on our policy of three grams or less at about $8 or $8.50 a gram.

[Shaun Chen]

That same report by the Auditor General also critiqued the department's management of the drug benefits list. Medicinal marijuana is one of many ways in which veterans address their medical concerns. It was recommended by the Auditor General that the department look at creating a decision-making framework that would seek specific evidence for deciding which drugs to reimburse and for how much. It was also identified in the Auditor General's report that when they looked at a number situations where veterans were given drugs, there wasn't sufficient evidence as to how those drugs would be helpful to them in those situations. To me this sounds like a larger problem.

How would you say the department is now viewing the drug benefits list? How are they better managing it? Are you more or less relying on the due diligence of physicians prescribing these drugs or medicinal marijuana to give their patients the best medical advice that they need?

[Dr. Cyd Courchesne]

Following this report, we totally restructured our formulary review committee. We restructured the membership. We put in guiding principles to make decisions, and evidence to be weighed to decide on whether we would or would not list a drug. Cannabis aside, all the other drugs go through the Canadian review committee. In Canada there are recommendations to list or not. We consider those recommendations. We also align with the Canadian Armed Forces. We look at what drugs they have, because when the veterans are released, especially for medical reasons, we want to make sure we have the same drugs on our formulary so there are no gaps in health care as they leave the military.

We've done a lot of work since the report of the Auditor General. It was timely and useful for us to look at those recommendations and to make important changes to the way we manage the drug program.

There have also been some product listing agreements that we're looking at so that if a drug is bought by a federal agency, all the other federal agencies have the opportunity to have the drug at the same favourable price that we've negotiated with the producers.

We've done a lot of changes to the drug program.

[The Chair, Liberal, Neil Ellis]

Thank you.

For four minutes, Ms. Ludwig.

[Karen Ludwig]

Thank you, Chair.

Thank you both for your presentations today.

I'm wondering about the prescription itself. The first time someone asks for a prescription for marijuana, is the prescription automatically for a year?

[Dr. Alexandra Heber]

First of all, it's not a prescription. It's called an authorization, because in fact, unlike other medications that are prescribed by a physician, this is a natural plant that is being.... It's called an authorization. Obviously, the thought behind this was that a veteran or other person in Canada would go to their own physician. They would discuss all the pros and cons of using marijuana versus an antidepressant or something else for their condition, a decision would be made, and the person would be followed.

Unfortunately, in a lot of cases that's not what's happening. We have a small number of physicians who are authorizing a great amount of cannabis for veterans. If a veteran is being followed in one of our operational stress injury clinics, it would not be that psychiatrist. Some of them have, with the patient, tried them on cannabis, but the large majority are getting it from a physician outside of that care team.

This is a problem. I don't think it was a problem anybody could have anticipated, but unfortunately, there's a lot of profit to be made in cannabis.

[Karen Ludwig]

It sounds, Dr. Heber, that a lot of this has evolved over the course of time. I find it surprising there's been such a little amount of research since 2008. In fact, a number of the vets who are using marijuana as a form to try to manage PTSD are probably on other medications as well. Is there any research out there to look at the cross-referencing of medications and the adverse effects?

[Dr. Alexandra Heber]

Again, there's very little at the present time.

[Karen Ludwig]

Would you recommend that as an area for research?

[Dr. Alexandra Heber]

Absolutely. All of this should be researched.

What has happened is the use of marijuana, especially for medical purposes, has far outstripped the research, unlike what we would do with any other medication.

[Karen Ludwig]

I represent an area in New Brunswick. I know all of the usage in that province in particular. One of the companies in my riding of New Brunswick Southwest is actually a medical marijuana company well known for the research that has been done there, but they also do the testing on the different strains. Everything is bar coded. In terms of their research specifically they're focusing on PTSD. They will work through a group of doctors, and if there's an adverse effect, they're trying to go back to a particular stage in the processing of it. The other problem they're also recognizing is not everyone wants to take marijuana in a smokable form. They would rather have it in pill form or other forms.

I heard a number of veterans complain when we went from 10 grams down to three grams. Is it in fact the case that if a doctor gets recommended for the authorization the person could get an increase above three grams if it's approved by a doctor or a specialist?

[Dr. Cyd Courchesne]

What was your question again?

[Voices]

Oh, oh!

[The Chair, Liberal, Neil Ellis]

It was a long question. If you give the question, you will have to get back to the answer.

Karen, if you have it, we're just....

[Karen Ludwig]

The question was basically looking at the 10 grams down to three grams.