Proceedings of the Subcommittee on
Veterans Affairs
Issue No. 19 - Evidence - October 17, 2018
OTTAWA, Wednesday, October 17, 2018
The Subcommittee on Veterans Affairs met this day at 12:03 p.m. to continue its study on the services and benefits provided to members of the Canadian Forces; to veterans; to members and former members of the Royal Canadian Mounted Police and their families (Topic: study on cannabis use for medical purposes by Canadian veterans).
Senator Jean-Guy Dagenais (Chair) in the chair.
[Translation]
The Chair: Ladies and gentlemen, welcome to the Subcommittee on Veterans Affairs. Before we start, I would like to give senators an opportunity to introduce themselves, starting on my right.
[English]
Senator Boniface: Gwen Boniface, senator from Ontario.
Senator Griffin: Diane Griffin, Prince Edward Island.
[Translation]
Senator McIntyre: Paul McIntyre from New Brunswick.
The Chair: Thank you, ladies and gentlemen. I am Senator Jean-Guy Dagenais, Chair of the Subcommittee on Veterans Affairs. I would like to thank our two guests, Dr. Greg Passey and Dr. Édouard Auger, for accepting our invitation. Today we will continue our study on cannabis use for medical purposes by Canadian veterans.
Once again, gentlemen, welcome. We will listen to your presentations, starting with Dr. Auger, who is with us by video conference. Following your presentations, we will move on to the question period. Dr. Auger, we are listening.
Dr. Édouard Auger, Psychiatrist, as an individual: Thank you very much, Mr. Chair, for allowing me to speak to you on this very important topic, which has had, and is still having, a major impact on our clinical activities.
First of all, I have been a psychiatrist since 1998. Following my psychiatry residency, I trained in psychotherapy for post-traumatic stress disorder, and I began my work on that problem at the anxiety disorders clinic of the Institut universitaire en santé mentale de Québec. I was medical chief of that clinic from 1999 until I left the institute. I was also medical chief of the affective disorders program from 2006 to 2008. In 2007, I began my part-time involvement at the operational stress injury clinic, or OSI clinic, in Quebec City. The clinic is, of course, sponsored by the Department of Veterans Affairs. In 2008, I left the institute to join the OSI clinic on a full-time basis and have been its medical chief since then.
I am also a clinical professor in the department of psychiatry and neuroscience at Laval University, where I have mainly been involved in teaching cognitive behavioural therapy to psychiatry residents. I am currently taking part in a research project on the use of service dogs for veterans suffering from post-traumatic stress disorder. I therefore have extensive experience in the diagnosis and treatment of post-traumatic stress disorder among civilians and veterans.
I understand from your invitation, after reading the minutes of previous meetings, that you are mainly interested in my experience as a clinician who has treated patients suffering from this very painful and debilitating illness. I will therefore briefly describe to you what has happened in recent years and how we, as clinicians, have tried at our clinic to maintain a rational approach to protect the well-being of our vulnerable patients. I believe the exercise will help you understand the issues on the ground for clinicians.
In the 2010s, when we began talking about medical cannabis in the treatment of post-traumatic stress disorder, we were quite surprised. Incidentally, I say “we” here because I believe I am speaking for my medical colleagues at the clinic. We have had numerous discussions and communications on this subject in recent years. We were initially surprised because, speaking anecdotally, we had never really noted any benefits among the many patients who used cannabis. However, we were also curious since we had previously started using nabilone, a synthetic cannabinoid with no euphoric effects, in treating nightmares, since that problem had resisted other treatments.
You must understand that, at the time, Quebec had established a provincial registry for patients receiving medical cannabis. So we thought cannabis might perhaps become an experimental treatment, given the absence of recommendations and research data. We had thought at the time that we might establish advisory committees in our clinics to review cases for which we might consider prescribing the drug, while taking part in the provincial registry, of course. We were very naïve at the time. We were somewhat like people who walk on a beach where large waves have been predicted and who find themselves, at the last minute, facing a tsunami, without an emergency or evacuation plan.
To continue with the same analogy, we were inundated at the time with patient requests —
The Chair: Dr. Auger, I’m going to ask you to speak more slowly for the interpreters. Thank you very much.
Dr. Auger: — for prescriptions for cannabis. We turned to our governing bodies, in particular, the hospital and network of OSI clinics, and realized there was no policy at the time on that type of prescription. Of course, physicians refused to prescribe or authorize any such treatment, given the lack of research data and recommendations by professional associations, because our professional associations claimed at the time, and still do, that cannabis was not recognized as a treatment for psychiatric conditions.
In view of that refusal, patients readily circumvented the problem. With outside help, they were promptly put in touch with prescribing physicians who, in most instances, saw patients for a few minutes and then wrote the prescriptions. In most cases, those physicians practised outside the province of Quebec and were not subject to the provincial registry. Furthermore, those prescribers never contacted us for a clearer understanding of the patients’ issues and provided no follow-up on the patients’ condition. Many patients with, in my opinion, clear contraindications, such as histories of toxic psychosis, recognized and severe drug addiction problems and unstable bipolar conditions, found themselves overnight receiving 10 grams of cannabis per day delivered to them in the mail. In addition, in my experience, the vast majority of patients initially received the maximum possible dose, 10 grams per day, and subsequently 3 grams a day. Patients therefore came and consulted us for follow-up care and didn’t understand that we didn’t want to validate another physician’s prescription and that we were also reconsidering their involvement in other types of treatment at the clinic.
It has to be said, however, that just as I wouldn’t want the pilot on my flight to Regina to be smoking 10 grams of cannabis a day, a patient on the same dosage is completely incapable of undertaking or continuing psychotherapy of any value at all. This all resulted in major confusion. You can understand the tsunami image here.
We physicians therefore decided to prepare an in-house policy to establish a concerted, rational and flexible approach while trying not to harm our sickest patients. Without going into the details, the policy reaffirmed the fact that cannabis was not recognized as a valid treatment for post-traumatic stress disorder, that the clinic’s physicians would not prescribe it and that patients who received it would have their involvement in other treatments at the clinic reassessed. All this is still under way and is being assessed on a case-by-case basis. If the committee wishes, I can send it a copy of that policy, which was supported by all stakeholders at the clinic, whether or not they were physicians.
Of course, cutting the maximum dosage from 10 grams to 3 grams made the problem less significant, but, in our view, 3 grams a day is still too high a dosage in view of the recognized harmful effects of the substance.
Personally, I find that some patients who stick with dosages of usually less than 1 gram per day are the ones who appear to benefit most from what I admit are partial effects on sleep and anxiety. In that instance, they don’t change their medication and may take part in other treatments.
The same is true of a patient who uses non-prescribed cannabis or takes a non-problematic alcoholic drink. Should the cost of cannabis be reimbursed in the case of a psychological condition? I’m not sure, particularly since the American Psychiatric Association, one of the leading psychiatric associations, recently reiterated that cannabis is not a treatment option for psychiatric conditions.
In conclusion, I think that it’s way too easy for veterans suffering from post-traumatic stress disorder to obtain medical cannabis and that it can undermine their long-term recovery. At our clinic, we see, over time, that the health of patients who consume higher dosages of cannabis — following a honeymoon period — gradually deteriorates. They become apathetic, for example, or less functional.
It would be helpful for requests to be analyzed by assessment committees to prevent this experimental treatment from being perceived as a first-line treatment. Cannabis suppliers should be well regulated, and prescribers and suppliers should be independent of one another. Physicians should also be able to decide between two dosages and the type of cannabis used in order to prevent excesses.
So why has cannabis experienced an increase in popularity as a treatment for post-traumatic stress disorder? We can definitely look to the endocannabinoid system and the effects of CBD and THC, but there is another very important factor. Post-traumatic stress disorder is often a severe and debilitating illness, and it is true that current treatments are gruelling. The medications have secondary effects and limited therapeutic effects. Psychotherapies are also daunting and require considerable motivation and work on the patients’ part. Cannabis, on the other hand, offers dreams. It offers a quick alternative with no effort or pain. Patients are fragile and vulnerable to talk about miraculous treatments, and you can understand them. They need to be careful to avoid next day regret.
Thank you very much.
The Chair: Thank you very much for your presentation, Dr. Auger. Before we continue with Dr. Passey, I’m going to introduce Senator Wallin from Saskatchewan, who has joined us. Welcome to the committee, Senator Wallin.
Now we’ll continue with Dr. Passey’s presentation.
[English]
Dr. Greg Passey, Psychiatrist, as an individual: Good morning. I wish to thank you for this opportunity to once again provide medical information to this committee.
I will not go through all my background, suffice to say I served for 22 years in the military and have been doing PTSD assessment and treatment for 25 years since 1993. I have had the privilege to assess and treat military members from all of our wars, and almost every single UN or overseas deployment since Canada started to deploy overseas.
I would like to point two things out. First, in all that time, I have never had one of my patients commit suicide while they’ve been under my active care. The only soldier who has ever died under my care was Greg Matters when he was shot in the back by an RCMP ERT team that did not understand what they were dealing with and didn’t give me an opportunity to actually talk with my patient.
The research that Dr. Crockett and I did in 1993 formed the basis for the establishment of the Canadian Forces Operational Trauma Stress Support Centres in 1999, as well as the subsequent VAC Operational Stress Injury clinics.
It has been noted — and I’m taking a little bit of different direction than my colleague — that the mission of Veterans Affairs Canada is to provide exemplary client-centred services and benefits that respond to the needs of our veterans, other clients and their families in recognition of their services in Canada, and to keep the memory of their achievements and sacrifices alive for all Canadians. It is my opinion that this is not actually being practised, especially in regard to the VAC cannabis policy.
I first started prescribing medicinal cannabis in 2008. I got backdoored into this. I had numerous veterans who were using cannabis at that time and I did not want them to be in situations where RCMP standoffs were going to occur. I started to prescribe for them. During that time, I noticed something interesting. As the prescriptions went on, their need for prescribed medications decreased over time and they maintained their recovery process.
According to VAC, in 2016-17, there were over 4,400 veterans on medicinal cannabis. VAC spent $63 million. The average daily dose at that time was 4.6 grams. In 2017, VAC decided to limit the payments for all veterans to only 3 grams unless they had a specialist’s letter. There were over 7,200 veterans registered at that time and the daily maximum dose was forcibly dropped to 3 grams per day. This caused the overall average to decrease to 2.25 grams per day because of VAC’s unilateral decision to save money regardless of the effects on the veterans’ symptoms and well-being. If VAC had not forced this action on to our veterans and if the daily average dose had remained at 4.6 grams, it would have cost over $104 million. So VAC saved $53 million by instituting this medically draconian policy.
A previous presenter stated that this meets the Auditor General’s recommendations to contain costs while ensuring that the health and well-being of veterans is maintained. In actual fact, this policy was implemented without any regard to the effect on veterans’ health and their well-being. To my knowledge, no treating physician was consulted to discuss the effect of abruptly dropping the medicinal cannabis dose to only 3 grams on any of their patients. I had veterans, who had been stabilized since 2008, suddenly become very symptomatic again because of this policy. I received phone calls from veterans from all across the country because they couldn’t find a specialist to write a letter for funding and to prescribe greater than 3 grams.
Dr. Courchesne’s statement that “Fewer people are asking for an exceptional reimbursement” is very misleading. It is not because less is needed, but because there are too few specialists to meet the demand. Likewise, the comment that, “While the number of veterans seeking reimbursement continues to rise, the cost per veteran has decreased,” is also misleading.
In my opinion, the way this policy was initiated was ill-conceived and medically negligent. The Hippocratic oath states do not harm. This was not followed. The PTSD suicide rate is 19 per cent; up to 46 per cent actually have thought of suicide.
The previous presenters did not testify to even one positive clinical outcome because of this policy. Likewise, they did not testify to even one negative outcome. They actually have no idea about the clinical impact of this policy. The policy put many veterans at risk for a deterioration of their health, family function and suicide.
If VAC was really concerned about veterans, then the veterans who were already on medical cannabis would have been grandfathered and this policy would have applied only to new veterans seeking medicinal marijuana.
There has been a number of previous experts who have recommended a careful approach to cannabis and I agree with that absolutely with regard to new patients. Some experts have indicated 1 to 2 grams per day was a reasonable quantity. The difficulty with these recommendations is that no one is talking about whether it is Sativa, Indica or hybrid. What is the percentage of THC or cannabinoids? No one is talking about these things; they are talking about marijuana in general. This is equivalent to me saying, “Well, painkillers are bad for you.” What are we talking about? Are we talking about morphine or Aspirin? That is the difference: no one is talking about this with medicinal marijuana.
I was never contacted with regard to the impact on any of my patients. I have more than 200 patients at this point. No one from VAC has ever phoned and asked me about the impact. I had contacted Dr. Courchesne’s office and arranged for an appointment where we could speak and I could talk about my cases. The appointment came and went. The doctor never phoned me and none of my calls were returned.
When it is said that we don’t see any decrease in use of other classes of drugs, such as benzodiazepines or sleep aids, other than the growth in expenditures for cannabis, but other drugs basically have not changed, this is very misleading. The problem is they didn’t look at changes in medication in individuals who have actually been prescribed medical marijuana. I am careful with what I prescribe with regard to the percentage of THC versus CBD, for instance.
As an example, veteran B in 2009 was diagnosed with pain disorder associated with psychological factors and a general medical condition, major depression, chronic PTSD and severe pain; all of this sort of stuff. He had to use a cane and sometimes a walker. He had difficulty going up stairs, so I did his appointments on the main floor of the Saskatoon clinic.
Until he was prescribed medicinal cannabis, he was taking 10,000 prescribed pills per year from a doctor before I actually received this gentleman. His prescriptions included Clonazepam, Nortriptyline, Targin and Baclofen, which are painkillers, Oxycodone — which is a painkiller and addictive — Propranolol for anxiety, Gabapentin — a painkiller — Citalopram, which is an antidepressant, Fluvoxamine, Trazodone and Zopiclone.
I started him on medicinal cannabis in 2013. We started to taper his other medications while titrating his cannabis and he was tapered off all of his pain medications by December 2017.
He is currently on 10 grams of medicinal cannabis, which is high in CBD and lower in THC, that he uses as a suppository twice a day. He is being tapered off his last medication, Nortriptyline, and it will be discontinued before the end of this year. He now walks without a cane and he bought and uses a Ski-doo and a quad. He is fully mobile and his cognition is clear.
This policy continues to be a problem even for those vets who have been authorized greater than 3 grams in previous years. The denial is usually done by a nurse and there is no contact with the veteran or the prescribing physician before the denial is made. The decision time usually takes four to six weeks, even for those previously authorized, and an appeal is another four to six weeks.
During this time the veteran is deprived of this stabilizing medication. Unfortunately, I don’t think they have been translated yet, but I brought two examples of denial letters and despite me putting everything in there that VAC has asked for, the denial was done by a nurse. She never talked to me or about the effect on the veteran, and never talked to the veteran.
I’ve mentioned the issues about the various strains and THC versus CBD.
Senator Richards mentioned that cannabis covers up the problem but it doesn’t cure it. Dr. Wong stated that they aren’t getting well, necessarily; they may be masking some of the symptoms. I want to make this very clear: this can be said about every medication we use to treat PTSD. There is no cure for PTSD, just as there is no cure for something like diabetes. We manage it.
The side effect profile of medicinal cannabis versus all of our prescribed medications is much less harmful. The prescribed typical pharmaceutical medications’ side effects include sexual dysfunction, bruxism — which is the grinding and breaking of teeth — anxiety, movement disorders and impaired motor skills, to name but a few. There are numerous medications that are used off-label by physicians and psychiatrists. That means there are no random studies done or randomized controlled trials to support their use in PTSD, yet they are used anyway and their side-effect profiles are worse than what I see with cannabis, particularly CBD.
Dr. MacKillopp stated earlier that:
Furthermore, a number of studies have linked cannabis use to self-harm and suicide in . . . veterans.
As I have already noted, veterans with PTSD already have high rates of suicide. Dr. Jetly said:
We have evidence of the potential harm of marijuana, including apathy, depression, anxiety and psychosis.
These can also be the same side effects with our prescribed medications and the problem comes back, once again, to the fact that no one is talking about the different strains in the THC versus CBD.
I’d like to finish this presentation on the fact that the research is quite clear and has demonstrated that lack of support is as important as exposure to traumatic events in the evolution, severity and perpetuation of post-traumatic stress disorder. Recurrent VAC denials are perceived by veterans as a lack of support and contribute on a number of levels to the worsening of veterans’ psychological symptoms, and that is not just with regard to marijuana or cannabis, but with regard to all of their claims.
[Translation]
The Chair: Thank you very much for your presentation, Dr. Passey. Now we’ll move to questions with Senator Boniface.
[English]
Senator Boniface: A question for both of you. Dr. Auger, I note you use the term “medical” and Dr. Passey you use the term “medicinal.” What is the distinction, or are they equivalent?
Dr. Auger: Maybe you got that in the translation. In French I said “à fins thérapeutiques.”
[Translation]
So we’re talking about use for treatment purposes. I don’t think this is a treatment that’s usually medical because it isn’t currently recognized by medical associations. The French term I used wasn’t “médical” but rather “à des fins de traitement.” Does that answer your question?
[English]
Senator Boniface: Yes, thank you.
Senator Wallin: Welcome. I’m sure, Dr. Auger, that you might have spent some time at the CIMVHR conference under way in Regina. I was there for a couple of days, where everyone is wrestling with this issue. I would like to hear from both of you. Dr. Passey, you noted that we do not seem to have clinical outcomes — either positive or negative — because we actually haven’t done clinical trials because, of course, the substance was illegal. So now what happens? Dr. Auger, why don’t you start?
[Translation]
Dr. Auger: I’m a clinician, not a researcher. We hope to acquire more clinical data to demonstrate effectiveness, or lack thereof, and dosages depending on type of cannabis. We do sense that cannabis probably contains a molecule or a mix of various molecules that are useful. We also hope that more exhaustive research will be done. Some CBD compounds and THC-based medications are better controlled, and we now have a better idea of what we’re prescribing, instead of prescribing a plant that contains at least 100 active molecules. We would also like to obtain the approval of the scientific associations, which would demonstrate that the substance can be used, how and when.
[English]
Dr. Passey: That’s a very good question. For my patients, my preference is that they use oils because I then know exactly what the dose is and I know the percentage of THC versus the percentage of CBD. When you are smoking or eating it, I have no idea of the dose that you are getting.
The state-of-the-art standards now are randomized clinical trials. I understand that, but if we had waited for Edward Jenner when he first found that cowpox would prevent smallpox — they didn’t have randomized control trials back then. The reality is, most of medicine is based on observation. I have been observing this for a decade now. I have numerous cases. In the research community that’s called anecdotal, so they don’t give it much weight, but I have seen the difference. Does it work for everybody? No. Does it cure it? No, but it’s effective.
If I can get people off alcohol and opioids — which are highly addictive and known for suicide risk — by using something like a high percentage CBD cannabis, then I’m going to do that because it works. I’ll wait for the research to catch up. I’ll come back to do no harm. I am doing no harm.
Senator Wallin: That’s where the jury is still out until we get some kind of randomized clinical trials or any kind of testing.
So what’s the next step? Now that we have cannabis legalized to some degree, what do we do? Do we need to go to Veterans Affairs and say, please ask the veterans who are funded through Veterans Affairs to be part of a clinical trial? Can we do that in exchange for funding this product for their use?
Dr. Passey: You can’t coerce subjects. They’d have to agree. There would be a bit of a problem with that. It would be great for the veteran population, but the civilian researchers would be saying you have a biased population.
We do need randomized control trials, absolutely, but it’s difficult. It’s not just that we are going to study medicinal cannabis. Is it high THC, low CBD? Is it fifty-fifty? Is it low THC, high CBD? Which types of CBDs? There is a cannabinoid that’s good for sleep, do we isolate that? There are something like 87 different compounds in marijuana. I’m just trying to struggle with the oil.
There is a lot of work to be done. To be cutting off veterans now, when it’s proved effective in my patient population — maybe it’s very different from my colleagues — but in mine are stable and I have gotten them off of lots of medications. This is only a small percentage of my total population. Not all my vets are on medicinal cannabis. I don’t use it so I have no experience, but I see it works.
Senator Wallin: How do we get to actual testing? To clinical trials where we are testing apples to apples, not apples to oranges and pears and bananas?
[Translation]
Dr. Auger: That’s very difficult. Currently, since there are 7,000 veterans who use cannabis, it would be an interesting population to study to see how they evolve over time.
We don’t prescribe cannabis, but we don’t necessarily push patients out the door when they use it because some are very sick. We have to keep an eye on them. We monitor their progress. So it would be interesting to see how they evolve because we have a lot of patients who, after a period of time, are somewhat disappointed to see that cannabis gets them nowhere.
It’s not true that all the treatments always work very well. Many patients ultimately move on to something else. They come back to see us after two or three years and say they realize they aren’t on the right track and can’t function any more and ask us to find a solution. It would be interesting to take a look at that.
Conducting placebo-controlled studies is definitely a very complicated and complex process. You have to select the right doses. As Dr. Passey says, you have to know what you’re prescribing.
What I know right now is that, when we don’t prescribe cannabis — What we see most of the time is that cannabis is approved and the patient chooses the type of cannabis he wants to consume. I would say that, 90 per cent of the time, patients choose cannabis with high levels of THC in order to get the euphoric effect. Yes, some patients will take CBD, but not the majority. We don’t have any control over that. We’re opening a door, and we don’t know what will happen. That’s not how I practise medicine. I don’t have any control over the dosage they take.
[English]
Senator Wallin: What I would like to ask both of you is, whose job is this to start doing this? Whose bailiwick is it in?
[Translation]
Dr. Auger: I think we have to have independent institutions. The problem is that a lot of information is somewhat tainted by suppliers.
Somewhat like Dr. MacKillop, who is completely independent, I think we must encourage those research institutions where there are serious people who don’t have any conflict of interest with the cannabis industry. I think this should be entrusted to those people. We have to use currently accessible data, and we have to move forward. However, we also have to be cautious. I think we’ve opened a door far too wide.
I’m also speaking on behalf of the nine physicians at my clinic. We’ve seen more disasters than good outcomes.
[English]
Dr. Passey: Veterans Affairs has teamed up with the Canadian Forces. I can’t remember the acronym, but they are, in conjunction with a number of universities, looking at studies and research on the treatment of PTSD, and I think the issue around medicinal cannabis needs to be looked at.
I wanted to point out two other things which don’t seem to be mentioned. Our best treatment is actually our talk therapies. They have upwards of a 60 per cent success rate. That means somewhere in the neighbourhood of 40 per cent don’t get better with that. The medications are even lower, so we need to be aware of that piece.
The other thing that’s never been talked about — and most people don’t know about it and I learned this in the 1990s — there are three themes to PTSD. One is fear. The treatment works very well with exposure and those types of talk therapies. The other two themes are guilt and anger. The success rate with exposures therapy and CBT, unless you do this properly, is under 20 per cent. So we are dealing with a disorder that is very hard to treat. We need to see how well the cannabis situation will add to our talk therapies and allow people to move forward.
Senator Wallin: Would you agree to the DeGroote Institute that Dr. Auger cited? Would that be a good place for some research to be conducted?
Dr. Passey: I think any university-level organization that is unbiased — because there is a lot of bias out there right now — will look at this. It’s difficult, as I mentioned. There are all these different types of cannabis and percentages. It’s going to be a lot of money and a lot of work.
Senator Wallin: Thank you.
Senator Griffin: I have two questions. I’m from Prince Edward Island and the department of Veterans Affairs is headquartered there so I’m very interested in this topic.
In terms of medical cannabis for veterans, what specifically would you like to see the federal government do?
Dr. Passey: It’s difficult. To be honest, the government has influence over Veterans Affairs but doesn’t seem to be able to make them do anything. Part of the issue is that there needs to be research. There’s no doubt about that.
The one thing I would like to see from Veterans Affairs is, if I have prescribed somebody something — and this only seems to happen with cannabis — and the person has been stable on it and I have gotten them off all these other drugs, I would just like them to leave me alone.
I’m a clinician. If my patient is getting worse, I’ll deal with that. If I think they are using marijuana inappropriately, I’ll deal with that. But the reality is that most of my patients don’t use high THC and, if they are using that, it’s at nighttime because it helps with sleep and nightmares. Most of them are using higher CBD during the daytime for their chronic pain, anxiety and irritability.
The reality is I don’t want a nurse telling me, “We don’t think that this is appropriate, so we are cutting you off,” and my guy goes from 10 grams down to 3 grams. What does he turn to? Alcohol? Do I prescribe narcotics for his pain?
Let’s do the research, but for the ones that it’s working for, just let us do our medicine.
Senator Griffin: Can the patient still get 10 grams but only 3 grams is paid for?
Dr. Passey: Absolutely. The problem, though, is who can afford it?
Senator Griffin: That’s another issue, yes.
Dr. Passey: It is another issue.
Senator Griffin: As of today, as you know, it’s now legal to have recreational marijuana. Can you see what impact that might have on the use of medical marijuana? Will this be used as one of the things to make up the difference, especially going from 10 grams down to 3 grams?
Dr. Passey: I have to be truthful here. The minority of patients are on ten. Most of them are on five or less. In fact, a good chunk of them are on three. But I don’t get the easy PTSD cases. The OSI clinic refers the difficult ones to me, it seems like, particularly if cannabis is involved.
My patients have gone wherever they could to get supplemental if they have been cut off. The problem is the dispensaries often don’t know what percentage THC and CBD are there. We don’t know if it’s laced with other stuff. So they are at great risk when their supply is cut down.
Now, maybe it will be a little easier, because if it’s legalized and being sold out of legitimate stores, hopefully we’ll know. It should be, because most of the dispensaries, because of the cost, don’t do this. How much THC and how much CBD is in each of their products. Most of the time, up until this day, that has not been known. It may actually improve things to some degree, but, again, I’d like to see all my patients just on the oils, period, so I know exactly what the dose is.
Senator Griffin: Thank you.
[Translation]
Dr. Auger: I didn’t answer the previous question. I would’ve liked to respond to the idea of reducing the dosage to 3 grams. I agree with Dr. Passey that it’s not easy to pull back once you’ve opened the door to something. I understand that, when you’ve allowed something, it isn’t easy then to take it back, especially if it’s been shown to be beneficial over a long period of time. Consequently, legalization may perhaps help in a way.
That goes together with the second question on what the rules will be, given that cannabis will no longer be illegal and will be available. We may turn to things that are more recognized and recommended, and we may then ask ourselves whether it should be paid for or reimbursed. I’ve heard so many stories about people who receive 3 grams or 10 grams of cannabis. This may be an opportunity to refocus on what will be allowed or not.
The Chair: Dr. Auger, does permitting treatment with cannabis create dependency at some point? Once the treatment is finished, will the patient want to continue using it?
Dr. Auger: Cannabis isn’t the drug that causes the most dependence. The higher the dosage, the greater the risk of dependency. This hasn’t happened in a disastrous way, but we have had to send people for treatment at detox units authorized by the Department of Veterans Affairs. It was all paid for by the department. Paradoxically, we’ve prescribed a treatment to undo that treatment.
We’ve had patients who have been hospitalized, who have suffered from psychotic episodes. Many psychiatric emergency physicians have asked us what happened with our patients and why they were completely intoxicated. There’s a lack of control. Things have happened far too quickly. That’s why I referred to a tsunami. We’ve never had the time to reflect, to stop and realize that we can’t tolerate this. There may be a place for cannabis, but we have to find it.
What I think right now is that this is an experimental treatment. It’s becoming a first-line treatment for some of our patients. We go directly to cannabis. We don’t want to consider other approaches that are difficult but are recognized. Even though those therapies are tough, they’re recognized by the science. There are more than 200 or 300 studies showing that exposure therapies are effective. They are definitely hard, but they can work.
Senator McIntyre: Dr. Auger, I understand that your clinic is part of the network of operational stress injury clinics. However, here’s a December 2017 newspaper article that states that the team at the Clinique pour traumatismes liés au stress opérationnel in Quebec City sent a letter to Veterans Affairs Canada in 2016 expressing its concerns, citing, and I quote:
. . . [the] comments of patients who used high doses in order to provide cannabis to family members and friends or to resell it.
What did you mean by that? Are these isolated cases or does this involve a significant number of patients?
Dr. Auger: I didn’t count them, but these are things that were happening often enough to become troubling. I had to explain to patients that they had were not entitled to offer cannabis to family members since that was illegal. I had to explain to them that, from a legal standpoint, it was prescribed for them.
People weren’t aware. I heard that people were even reselling cannabis. I haven’t done any research on that, but we’ve heard it enough at the clinic that it concerns us. When you refer to that letter, that’s the policy that was prepared in 2016. That’s precisely the letter I sent to the clinical network at Veterans Affairs Canada and to our own hospital to state our recommendations.
Senator McIntyre: Do you think that reducing the amount of cannabis reimbursed by Veterans Affairs Canada to 3 grams solved that potential problem?
Dr. Auger: I think it improved the situation because we’ve stopped prescribing extreme dosages of 10 grams of cannabis. There are virtually no such cases now. Some individuals will wind up with more than 3 grams. I’m not saying that’s perfect, but, as a result of this limit, there are fewer major and unusual incidents and hospitalizations for psychotic episodes resulting from cannabis treatment. This is still a problem, but I admit it has enabled us to take a step back and not put patients in situations where they have to choose their treatment. We’re in a better position to keep them and encourage them to take part in other treatments and reduce their cannabis consumption.
[English]
Senator McIntyre: My next question is addressed to both witnesses. Are there gender considerations to take into account with respect to the use of medical cannabis?
I notice you are smiling.
Are there indications cannabis could affect men and women differently? Do men and women face different barriers with regard to the use of medical cannabis?
Dr. Passey: That’s a really great question. We don’t know. Most of the studies are done on males and they are not necessarily looking at differences.
The majority of members that serve are male not female. I don’t have a lot of women who are on marijuana. Having said that, I’m always concerned if they get pregnant, that’s a big issue in regards to the fetus-brain development. If they are breastfeeding, again it’s an issue. Those are things I would talk about.
Maybe my colleague would know more about that. Right now, as far as I’m aware, we don’t know of a difference. Size does make a difference. It’s distributed through the fat, and in fat in women versus males, there is a difference. I would expect there would be a difference, but I’m not aware of any studies. There haven’t been enough is the problem.
Senator McIntyre: I’d like to go back to the question I asked Dr. Auger a while ago regarding patients using high doses to supply cannabis to their family members and friends or to resell it. Have you come across that situation?
Dr. Passey: I personally have not. Have I heard of it? Yes, I have. Do I suspect it? It may be occurring. Again, I keep a fairly close eye on most of my patients regarding marijuana.
The stuff you would sell would be high THC. I don’t have a large number of veterans on high THC. They may be on both where they use CBD during the daytime and some THC at night. I have probably two or three with high THC. That may be a difference of metabolism or what their need is. I’m not personally aware of any.
We may have different patient populations. I have had one patient since 2008 who developed a psychosis in all the patients I have assessed and treated with marijuana. The reason he did that is he doubled his dose without me knowing. Once we cut it down to the dose I had suggested, the psychosis went away.
I’m not seeing hospitalizations. I know there are veterans who attend clinics. A GP gives up to three grams and they get the prescription and away they go. I don’t do that. I don’t think that’s good medicine. You need to follow those patients on an ongoing basis and look for the very things my colleague has spoken about as far as potential side effects.
[Translation]
The Chair: I have a few questions before I close the meeting. Dr. Auger, according to your research, there is a desire to minimize the euphoric feelings that some veterans get, and the term “medical” is used. Isn’t that a factor that facilitates cannabis use? As you mentioned, sometimes it’s difficult to provide follow-up care under this kind of treatment.
Dr. Auger: I’m not sure I understand the question.
The Chair: You said that the drug is designated as “medical.” Is that designation a factor that facilitates cannabis use but prevents you from providing follow-up care to the patient?
Dr. Auger: Yes, I called it that because it’s ultimately not something that’s under medical supervision. It’s allowed in our part of the country, but there’s no control. I can’t call it a medical treatment because there’s no medical follow-up. I agree with Dr. Passey. If treatment is provided, there has to be follow-up. It’s essential, and it’s not being done in this case.
The Chair: My question is for Dr. Passey. You mentioned the savings that can be achieved when the Canadian Armed Forces reimburse the cost of cannabis treatment. Isn’t it all interconnected? You prescribe cannabis, it’s reimbursed by the Armed Forces, and it saves money, but doesn’t that increase the cost of other drugs that are reimbursed by the Armed Forces?
[English]
Dr. Passey: Let me make a quick correction. The Armed Forces doesn’t pay for cannabis. It’s not done. It would be Veterans Affairs.
The point I was making was that Veterans Affairs saved a whole lot of money by cutting back. Part of the rationale for that was the cost, but also they weren’t seeing any difference in the prescription rates and costs of the other medications. My concern is it’s misleading because they weren’t actually looking at veterans who were on medication and then prescribed cannabis. What happened to those other medications?
Almost every patient I have ever treated with cannabis, their other medication have gone down. Is there an overall cost savings? I don’t know because I don’t know what the other medications cost. Nobody has looked at that. Cannabis is not cheap. It’s $8.50 a gram. That’s what VAC will pay for it. For the opioids and anti-depressants, the costs add up. I don’t think there would be an overall saving with the cannabis, but I do think they have to take into account the decrease of these other medications when cannabis is added to the treatment regime.
[Translation]
The Chair: I’d like to close with a topical question for our two guests. Do you think the authorized sale of recreational cannabis, at prices that will be quite low in Quebec and elsewhere, could put downward pressure on purchases of medical cannabis?
Dr. Auger: That’s an excellent question that’s very hard to answer. The issue of social acceptability often arises. People tell me, “I want to use cannabis, but I don’t want to be arrested by the police.” If that acceptability is there, perhaps people won’t come and ask us for prescriptions. They’ll simply go and purchase their cannabis in the same way they purchase beer on Friday night.
[English]
Dr. Passey: It’s an excellent question. There are approximately 292,000 people in Canada using cannabis for medicinal purposes. Part of the problem is the regulations and quality assurance et cetera that are necessary when you are prescribing a medicinal product. So that keeps the medicinal side high. However, scale of production — again I’m not an economic expert — but I happen to be working with a company that we are putting together called veterans initiative program. We are looking at things such as the cost of marijuana. We are interested in medicinal marijuana and the oils particularly.
There will be certainly a market adjustment to the cost. The major producers are really scaling up; 350,000 square feet of production. It’s happening all through B.C. and I expect through Canada. There should be a reduction in costs on the recreational side. Hopefully that will bring down the medicinal side. But, again, if you are using the oils, there is extraction, purification and a bunch of things which are necessary to go that route. So will it bring it down? Absolutely.
For instance, in Canada a pound of cannabis right now is approximately $3,800. I can get the same cannabis in Africa for a dollar. So, there is the possibility of absolutely bringing down the cost.
[Translation]
The Chair: If there are no further questions, we will adjourn. Thanks to our two guests, Dr. Auger and Dr. Passey, for their excellent testimony.
(The committee adjourned.)