Proceedings of the Subcommittee on
Issue No. 14 - Evidence - May 2, 2018
OTTAWA, Wednesday, May 2, 2018
The Subcommittee on Veterans Affairs met this day at 12:02 p.m. in public, 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); and in camera, to continue its study on issues relating to creating a defined, professional, and consistent system for veterans as they leave the Canadian Armed Forces.
Senator Jean-Guy Dagenais (Chair) in the chair.
The Chair: Before we begin, I will ask my fellow senators to introduce themselves, starting on my right.
Senator Boniface: Gwen Boniface, Ontario.
Senator Griffin: Diane Griffin, Prince Edward Island.
Senator McIntyre: Paul McIntyre, New Brunswick.
Senator Wallin: Pamela Wallin, Saskatchewan.
Senator Richards: David Richards, New Brunswick.
The Chair: I am Senator Jean-Guy Dagenais from Quebec. I am the chair of this committee.
Today, we begin our study on cannabis use for medical purposes by Canadian veterans. We have with us by videoconference Faith McIntyre, Director General, Policy and Research Division, Strategic Policy and Commemoration, Veterans Affairs Canada, and Cyd Courchesne, Director General, Health Professionals, and Chief Medical Officer, Veterans Affairs Canada. Welcome to you both.
We will start with Dr. Courchesne’s presentation. After that, we will hear Ms. McIntyre’s presentation and then move to the time for questions.
Dr. Cyd Courchesne, Director General, Health Professionals and Chief Medical Officer, Veterans Affairs Canada: Thank you, Mr. Chair. My name is Cyd Courchesne. I am the Director General, Health Professionals, and Chief Medical Officer, Veterans Affairs Canada. I am pleased to be here today with my colleague Faith McIntyre, Director General, Policy and Research Division, Strategic Policy and Commemoration. We thank you for the invitation to appear before the committee as it studies cannabis use for medical purposes by Canadian veterans.
We will briefly touch on the reimbursement program for cannabis for medical purposes at Veterans Affairs Canada, the data on the program uptake, the approvals process for reimbursement exceeding 3 grams per day and the most recent research data available to the department.
The mission of Veterans Affairs Canada is to provide exemplary, client-centred services and benefits that respond to the needs of veterans, our other clients and their families, in recognition of their services to Canada; and to keep the memory of their achievements and sacrifices alive for all Canadians.
Our goal is to ensure that veterans and their families receive the care and support they need.
In 1999, legal access to possess dried marijuana for medical purposes was first approved. Since then, as a result of many court decisions, the way individuals access cannabis for medical purposes has changed significantly.
Veterans Affairs Canada has provided coverage for the cost of cannabis for medical purposes since 2008.
Between 2008 and 2014, reimbursement was based on section 4 of the Veterans Health Care Regulations and in accordance with Health Canada’s Marihuana Medical Access Regulations. The Marihuana Medical Access Regulations, implemented in 2001, provided limited access to marijuana for medical purposes for a number of conditions and circumstances as defined by Health Canada when authorized by a specialist only.
In April 2014, Health Canada introduced the Marihuana for Medical Purposes Regulations, which removed limitations related to the authorization for specific conditions and the requirement for authorization by a specialist was changed to a medical authorization. It also provided individuals with a medical need to access quality-controlled dried marijuana produced under secure and sanitary conditions by licensed producers. In June 2015, licensed producers were permitted to produce and sell cannabis oil and fresh marijuana buds and leaves in addition to dried marijuana.
In August 2016, Health Canada’s Access to Cannabis for Medical Purposes Regulations were introduced, which set out provisions for individuals to grow a limited amount of cannabis for their own medical purposes or to designate someone to produce it for them.
While cannabis for medical purposes is still not an approved therapeutic drug in Canada, the access continues to grow. With the advent of these new regulations, Veterans Affairs Canada subsequently experienced a significant increase in requests for cannabis for medical purposes reimbursement.
In its spring 2016 report, the Office of the Auditor General recommended that Veterans Affairs improve management of its drug benefits program to consider the health and well-being of veterans as well as cost containment. As a result, the department conducted an internal review of its management of cannabis reimbursement, which involved consultation with medical professionals, subject matter experts, licensed providers and veteran beneficiaries.
The result of this review led to the implementation of Veterans Affairs Canada’s Reimbursement Policy for Cannabis for Medical Purposes in November 2016.
The 2016 policy allows eligible veterans to be reimbursed for a maximum of 3 grams per day of dried marijuana or its equivalent in cannabis oil and fresh marijuana at a fixed rate per gram.
The decision to provide reimbursement for 3 grams per day is based on the information we obtained through our consultations and from current research data. The department convened a group of experts in the medical field that recommended a careful approach to cannabis use for medical purposes. Most of those experts indicated that 1 to 2 grams per day was a reasonable quantity in most cases.
Veterans Affairs Canada also reviewed current scientific evidence and consulted with veterans, stakeholders and licensed producers. The proposed amount for reimbursement is also consistent with Health Canada data, which indicates that the average Canadian accesses less than 3 grams per day.
The approval process to obtain reimbursement from Veterans Affairs Canada for cannabis for medical purposes requires that the veterans have an authorization from a medical practitioner and that they be registered with an approved licensed producer from Health Canada’s website. The documentation is received by Medavie Blue Cross, who sends it to Veterans Affairs Canada for a decision. Medavie Blue Cross then sends the decision letter to the veteran on behalf of Veterans Affairs Canada.
To ensure greater rigour in the department’s approach, an approval process for exceptional requests was established when the policy went into effect in November 2016.
While a reimbursement request for 3 grams or less requires the approval of a family doctor, or a nurse practitioner in certain provinces, requests for more than 3 grams are approved only if they are accompanied by additional documentation from a specialist with expertise in the condition with which the veteran has been diagnosed.
For example, if the veteran is eligible for treatment benefits associated with a mental health condition, the specialist’s document would be provided by a psychiatrist. If it’s for pain due to cancer, then an oncologist would provide the supporting documentation.
Each exceptional claim is reviewed on a case-by-case basis, and the medical specialist’s supporting document must include a rationale for the use of more than 3 grams per day, confirmation that there are no contraindications when using cannabis for medical purposes and an indication that alternative treatments have been ineffective or contraindicated.
Furthermore, an administrative decision was made to set the maximum number of grams for an exceptional approval at 10 grams per day.
Similar to the other treatment benefits reimbursed by Veterans Affairs Canada, the exceptional approvals process is a mechanism to help to ensure that the health and well-being of the veteran remain at the forefront of the decision.
In 2017-18, 7,298 veterans received reimbursement from Veterans Affairs Canada for cannabis for medical purposes, at a cost of about $51 million.
While the number of veterans seeking reimbursement continues to rise, the cost per veteran has decreased. An analysis of expenditure data for the nine-month period between April 1 and December 31, 2017, revealed expenditures of $39.3 million. Had the 2016 Reimbursement Policy on Cannabis for Medical Purposes not been in place, it is estimated that the cost would have been $91.5 million for the same time period, indicating a potential cost savings of $52.2 million. This meets the Auditor General’s recommendation to contain costs, while ensuring that the health and well-being of veterans is maintained.
A comparison between the months of December 2016 and December 2017 provided additional evidence on the impact of the new policy. In December 2016, the department provided reimbursement for an average of 155 grams per eligible veteran, at an average cost of $11.28 per gram. In December 2017, the amount reimbursed decreased to an average of 89 grams, at an average cost of $8.38 per gram.
On December 31, 2017, approximately one year after the reimbursement policy was implemented, of the 6,119 veterans with active medical authorizations from their health care providers, only 734, or 12 per cent of the total, had exceptional approvals in place. This is in sharp contrast to the previous year when, as of December 31, 2016, there were 2,771 veterans, or 60 per cent of the total recipients, who were authorized for more than 3 grams per day. This decline in the number of veterans requesting reimbursement for over 3 grams also falls in line with Veterans Affairs Canada’s focus on supporting the health and well-being of veterans and their families.
Veterans Affairs Canada is working closely with the Canadian Armed Forces in directed research. Specifically, we are supporting a clinical study examining the efficacy and safety of cannabis as a mental health or physical health intervention among Canadian Armed Forces members and veterans. This will strengthen the evidence on the effects of marijuana on the health of veterans and inform our policies, while at the same time recognizing our collaboration with Health Canada as a significant lead on cannabis for medical purposes across the board.
Thank you. I will be happy to answer your questions.
The Chair: Thank you very much for your presentation, Ms. Courchesne. Before I give the floor to Ms. McIntyre, I would like to acknowledge the arrival of Senator Jaffer from British Columbia.
We will now move to Ms. McIntyre’s presentation. Ms. McIntyre, do you have a presentation for us, or do you just prefer to answer our questions?
Faith McIntyre, Director General, Policy and Research Division, Strategic Policy and Commemoration, Veterans Affairs Canada: I have no presentation. I did it jointly with Ms. Courchesne.
The Chair: Thank you very much, Ms. McIntyre. We will now move to the period for questions.
Senator Wallin: I want to get some assessment because I’ve written down all of the numbers, and I’m confused. Are more veterans using medical marijuana? Are they using more? If that’s the case, why is it costing less?
Dr. Courchesne: Yes, there are more veterans. Last year, we had nearly 7,300 veterans, but they’re using less. That’s why the costs decreased.
Senator Wallin: And why is that?
Dr. Courchesne: Because of the introduction of the policy that put in a limit of 3 grams. So most are accessing the 3 grams. Fewer people are asking for an exceptional reimbursement, and, also, the cost was negotiated at a fixed rate with most of the licensed producers. So there’s no variation in the price per gram. So the combined effect of fewer grams per veteran at a fixed rate resulted in a decrease in the cost.
Senator Wallin: On the status of the research, you said you’re looking at directed research and a clinical study. This is an issue that we find in this discussion all the time surrounding PTSD. I think that, in cases of cancer, it’s pretty clear cut, but, for medical marijuana usage for PTSD, do you feel comfortable that you have a clear enough definition? Let’s just examine that issue. How do you decide? Is it just left to the individual doctor to say, “Yes, there are enough signs here that I believe this qualifies?”
Dr. Courchesne: That’s a very good question. We monitor the signs very closely. The difficulty in the medical realm is that there is insufficient science. There’s no clear no; there’s no clear yes. There are several reasons for that. One is because cannabis is still a proscribed substance, so researchers have difficulty submitting research ethics proposals and passing the ethics board because it’s still a controlled substance. So that’s the one difficulty.
There is a lot of, I would say, anecdotal reporting, but very rigorous, randomized controlled trials, which are the gold standard for research, are still lacking. That’s why we’ve decided to partner with the Canadian Armed Forces. They approached us. They said we have an opportunity where we can do some clinical trials, and we’ve agreed to partner with them because there are still gaps.
With respect to authorizing it for PTSD, I just want to remind you that cannabis is not an approved therapeutic drug anywhere. It has not been developed as a drug. It has not undergone the clinical trials, and there is no prescribing pathology for it. So it’s very much left to the individual physicians that treat the veterans to decide if this is something suitable for them or not. Our decision is with respect to reimbursing it.
Senator Wallin: You’re kind of in a no-man’s land there.
Dr. Courchesne: We are. Well, we don’t prescribe, but we reimburse.
Senator Wallin: How are you anticipating the impact of legalization on this?
Dr. Courchesne: Well, I think there are two separate issues. I think we can’t mix recreational with medical.
Senator Wallin: Right, but in terms of access and cost?
Dr. Courchesne: I can’t predict how that’s going to impact it.
Senator Wallin: But you can’t foresee costs going down dramatically or huge savings?
Dr. Courchesne: That’s something that the producers would have answers to.
Senator Wallin: Can we see if Ms. McIntyre would like to make any comment?
Ms. McIntyre: Thank you very much. We are certainly actively engaged with the work that Health Canada is doing on the legalization. As Dr. Courchesne noted, they are on really separate tracks, the medical versus the legalization for recreational use.
Having said that, however, from a policy perspective, we don’t anticipate any need for adjustments to our reimbursement policy. However, on the operational side, things such as cost and access are actually two of the items that we’re tracking quite closely. In particular, for example, the taxation which has been proposed through the legalization and held back would then have an impact on the cost we have determined as a fair market value per gram.
At the same time, as noted by Dr. Courchesne, our policy is a document that we will continue to analyze as this work evolves. We need to be very conscious of what’s going on in the environment. At the same time, we need to be nimble in order to ensure that we’re providing the best reimbursement policy that we can, looking at the safety, well-being and security of our veteran population.
Senator Wallin: When you say you’re looking at the taxation aspect that the federal government or the provinces will impose, do you mean because that might impact the cost? Do you think that will impact the cost, making it higher? Is that your assumption?
Ms. McIntyre: It is in relation to impacting the cost. Regarding the excise duty and the cost, or what that will look like, we’re uncertain at this time. I certainly anticipate it will make it higher, and at that point in time we will have to operationally look at what we’re reimbursing on a per-gram amount.
Senator McIntyre: Dr. Courchesne, you mentioned that the Canadian Armed Forces and Veterans Affairs Canada would like to conduct a study on the effects of cannabis on members of the military and on veterans suffering from post-traumatic stress disorder. Where does the department stand on the study?
Dr. Courchesne: Thank you for the question. The research directorate has teamed up with the Canadian Armed Forces, and researchers have been recruited to conduct that study. They are in the process of developing the research protocol and going through the approval steps required by the research ethics committee. So, things are under way. We expect to begin the work in the summer of 2018.
Senator McIntyre: Do you have any obstacles that are slowing down the study or preventing it from getting started?
Dr. Courchesne: No. Developing research protocols requires a lot of preparation. It takes perhaps five times as long as the research itself. People think that it is simple, but it involves a lot of stages and a lot of back-and-forth among the researchers. It is also a collaboration with a number of partners. So we need time to get through all the stages.
Senator McIntyre: My next question goes to both our witnesses. In your opinion, what impact will legalizing the recreational use of marijuana have on veterans using marijuana for medical purposes?
Dr. Courchesne: With medical use, since we have a reimbursement policy, those clients will continue to ask for reimbursement. Will legalization mean that more people are going to self-medicate because it is legal? That is possible. It is a little like alcohol. People self-medicate with alcohol inappropriately, but we cannot control that. There again, it will be up to physicians to discuss the appropriate use of the substance with their patients.
Ms. McIntyre: I do not think there will be an impact on our policy, because it works by reimbursement. Veterans who want a prescription for medical marijuana have to abide by the criteria in our policy. If they want more than the limit we reimburse under the policy, it will be up to them to decide. We hope that they will make the decision after consulting their physicians.
Senator McIntyre: I am concerned that marijuana use by veterans continues to increase and that the costs also continue to increase in quite a calculated way. I see, for example, that last year — as you mentioned, Dr. Courchesne — the costs tripled compared to the previous year.
Dr. Courchesne: Actually, the figures have gone down. A greater number of veterans have received medical marijuana prescriptions but the total amount has gone down. In 2016-17, about 4,500 veterans took advantage of the benefit, at a cost of $63 million. In 2017-18, there were more veterans, but the cost was $50 million. So we saw a drop of a little more than $12 million.
Senator McIntyre: The figures I have in front of me show that the costs increased from 2013 to 2017. For example, in 2013-14, the cost was $409,000. In 2015, it was $12 million, and, in the 2016-17 financial year, it was $63.7 million. Those are the figures I was given.
Dr. Courchesne: Yes, you are right. In 2013, 112 veterans received a prescription.
Senator McIntyre: So more veterans used it?
Dr. Courchesne: Yes. That is a consequence of the change in Health Canada’s regulations that removed the requirement to have the approval of a specialist. They opened it up and said that any physician could sign an approval. We saw an explosion in the number of requests and approvals signed by physicians in the community.
Senator McIntyre: That explains the figures?
Dr. Courchesne: That explains the figures. At that point, they no longer had to go and see a specialist to get the prescription. They could ask their family doctor for one. That is where we saw the costs to the department change. It is a direct consequence of the change made in June 2014.
Senator Griffin: It’s interesting that the cost of marijuana is decreasing even though the use is rising. There are two things I was wondering. Are other drugs being used less now as a result for pain or sleep disorder and, therefore, the cost of those drugs would be decreasing?
Dr. Courchesne: Thank you for your very interesting question, one that we asked ourselves. We did look, and we didn’t see any decrease in the utilization of other classes of drugs, such as benzodiazepines that would be used for sleep aids or anxiety, or in the opioids. There was no drastic change, neither up nor down; it stayed constant. It might be too early to see a change in that because trends like that can take some years before we see an effect.
Senator Griffin: It’s still quite possible that could happen?
Dr. Courchesne: It’s possible, but right now we haven’t seen any of that.
Senator Griffin: When someone makes a request as an exceptional circumstance to get more than 3 grams reimbursed, why would such a request be refused if there are doctors saying they need this?
Dr. Courchesne: Thank you. Another very good question. What’s available in the literature right now and what we know about the usage of cannabis for various medical conditions does not support more than 3 grams a day.
When we changed our policy and put in that limit, it was based on expert panel opinion, medical specialist opinion. We talked to veterans also to ask because they told us anecdotally that it was helpful. We talked to licensed producers who told us that other than veterans the average Canadian uses less than 1.8 grams a day. We looked internationally also. We could only find two groups of people outside of Canada who did reimburse it. The amounts were low — 0.68 in the Netherlands and 1.5 in Isreal. We thought there is no reason to prescribe more. If you do want more, we want your doctor to convince us that this is the only thing that will work for you because we are concerned about the well-being of people, and the science is not there. The practice of medicine is an art; it’s not an exact science. People have different interpretations; so we wanted to ensure we had a good rationale.
Senator Griffin: Some people, obviously, are still being approved if the mechanism is there?
Dr. Courchesne: Yes.
Senator Griffin: Thank you.
Senator Jaffer: Thank you very much to both of you for making yourselves available.
My question is to expand on recreational cannabis and more so on the issue of stigma. At the moment, part of our society may frown on marijuana, and even though we don’t have the science, we know people feel better and the pain improves for some reason. The science is still not there; we’re still at that stage.
When the stigma is removed, do you think more veterans will want to use it for medicinal purposes?
Dr. Courchesne: That’s an interesting question.
Senator Jaffer: If you can’t answer it, that’s all right.
Dr. Courchesne: I understand about the stigma. In our expert panels and discussions with veterans and producers, we approached this as we would anything else, with scientific rigour. We try to be respectful. Even though the science is not there, not to dismiss it, which is why we consulted with veterans. We try not to use words like “weed” and “smoking weed.” That’s why we talk about cannabis use for medical purposes.
In French, people say pot. I refuse to use that term because the media will use it. We said that we were not going to talk in those terms, because people are suffering and are asking us for reimbursement for specific reasons. We have to use some scientific rigour in our decisions, because costs are involved.
But we try to be respectful of the veterans and not use terms that would stigmatize it further. We do want to keep the lines of communication open with veterans. We want to keep them informed of why we’re making these decisions. We want to keep them informed about why we’re changing our policy.
Will the recreational use affect the stigma? I don’t know. If we keep our approach respectful with veterans, they will continue to want to engage with us. That is the best answer I can give.
Senator Jaffer: I’m asking you to do a little bit of crystal ball gazing, and you are being careful. I respect that very much.
There is also this idea that cannabis for medical purposes can help reduce — more than an idea, I believe — medications such as opioids for pain, insomnia and anxiety. You’ve seen a lot of changes. Have you seen an increase in using marijuana, compared to others, like for sleeping or certainly for pain?
Dr. Courchesne: We do look at not just the expenditures but the usage of all the drugs that are on our benefit list. When we saw increases in the use of marijuana, we wanted to see if there was a correlated decrease in other classes of drugs. Other than growth in expenditures for marijuana, we didn’t see any change in the other classes of drugs, whether they be for anxiety, pain or sleep. That stayed the same.
Senator Jaffer: This has nothing to do with marijuana, and if you don’t want to answer it, I will respect that, but I can’t miss this opportunity when I have you here. We do study veterans; we have a report coming out. One of the things that many of us get nabbed on is the issue around medical support for veterans.
Generally, can you speak on how we could make recommendations to give you more resources to improve? I know you would say to give us more money. I get that. Is there anything specific, especially around returning veterans and PTSD?
Dr. Courchesne: I’m not sure I understand your question.
Senator Jaffer: We have heard we need to do more medical support, for example, with counselling, especially of recent returning veterans around PTSD. We had that terrible case in the Atlantic. Can you educate us on what more we can do?
Dr. Courchesne: Thank you. Part of my job as Director General of Health Professionals and Chief Medical Officer is to look at what supports we have. The more visible veterans are those that suffer from mental health. They represent about 25 per cent of our clients. Seventy-five per cent of our clients have needs other than mental health. But mental health is always very front and centre. Part of my job is to make sure that the supports are there.
I’m sure you’re aware that we have a national network of mental health clinics that we have established in partnership with our provincial health authorities, provincial colleagues. We monitor constantly to see if we have enough resources to meet the demand. We keep looking at other things that are out there, other therapies, emerging therapies and ways that we can give access to the greatest number of veterans in need as possible.
We do that on a regular basis. I can tell you that we have a gap in this area, and I really need more resources for that. It’s an ongoing thing that we look at. From all of our programs, also.
Senator Boniface: Thank you very much for being here. It’s a most interesting subject. I appreciate that you’re sort of new in terms of evaluating whether this will reduce the opioid use, but I was interested in whether the THC level varies or whether there is one constant, so a gram is a gram is a gram. Or can you prescribe by THC content as well?
Dr. Courchesne: Excellent question. There are about 70 active ingredients in cannabis, and there are two major classes — the THC and the CBD. There are an infinite number of permutations possible. I’ll bring you back to your high school math, where you had to do permutations with those complicated grids. It’s infinite. Because there is no pathology for cannabis, this is what makes it challenging. It’s not like an antibiotic that I prescribe to you at 250 milligrams, three times a day. I know where it’s acting, what it’s going to do, how it’s going to affect the bacteria. With cannabis, there is not that. That’s why most practitioners adopt the “go low, go slow” approach. It’s a titration thing. It’s trial and error, trial and error, trial and error. The CBD is what is hypothesized would act on pain and other symptoms like that. The THC is what makes people high. Nobody has found the magic formula for that. It probably varies by the individual who uses it also, which makes it, again, challenging.
Other than that explanation, I’m not a chemist, so I can’t go into any more detail. Perhaps some producers have more knowledge of that.
The Chair: I have a few questions for you, Dr. Courchesne. In terms of any follow-up done of the veterans using marijuana, have you seen any cases of severe abuse or dependence as a result of the marijuana prescribed for medical reasons?
Dr. Courchesne: Thank you, Mr. Chair. We do not do medical follow-ups.
We reimburse the prescriptions submitted to us that have been written by a treating physician. It is up to treating physicians to do any medical follow-ups. We have no authority to do so. We have no access to medical records. We have no access to information like that. So it is difficult for us to do any tracking along those lines.
The Chair: Have alternative programs to the use of marijuana been proposed? If you approve all the requests made according to the rules, have any alternate programs been proposed?
Dr. Courchesne: Yes, they have, but, there again, we do not do medical follow-ups on the clients. We issue reimbursements for other programs. For example, if patients are sent to a pain clinic, they will be reimbursed. Programs like that last a month. There are other solutions to replace marijuana, but we can have no control over them. We cannot call treating physicians to ask them if they have thought about this or that. Veterans have access to other reimbursement programs.
The Chair: Compared with other reimbursement programs in insurance, are those reimbursements restricted to veterans, or do they apply to family members? How does that work with other insurance companies?
Dr. Courchesne: For cannabis, only veterans are entitled to it, veterans either of the Canadian Armed Forces or the RCMP, but not family members. No.
The Chair: Thank you, Dr. Courchesne.
Senator Richards: Perhaps this has been answered because you said you don’t follow up with the doctors, but I was wondering: Do many of these veterans continue with therapy or continue to seek help for their post-traumatic stress disorder? Marijuana is not a cure-all for this. It covers up the problem, but it doesn’t cure it. I’m just wondering if they stay in therapy or continue getting help, or do they walk away from it?
Dr. Courchesne: Thank you for your question.
I can’t answer that question with accuracy. I do know that many of our veterans are clients of our mental health clinics, and this is reported by the clinical staff to us. They will see clients, even though they are using marijuana, but I can’t tell you with any accuracy how many have used and discontinued and all of that.
Is it possible? Yes. But I wouldn’t have the answer on that.
Faith, did you want to add something?
Ms. McIntyre: No. Thank you for asking, Cyd. It’s not something that we would track. We can certainly say that we have supports available, and it’s through those conversations, possibly with our case management team, our clinical staff, who would be under Cyd’s direction, above her team members, that we would counsel them in that regard. Indeed, it’s not one and not the other. It’s usually a whole, holistic approach that needs to come into play with regard to various conditions, particularly mental health.
The Chair: If there are no further questions, I would like to thank our witnesses for their testimony. You will be of great help to us as we prepare our report.
Before we close, however, I am going to ask all senators stay for a few minutes so that we can approve our report.
Thank you very much.
(The committee continued in camera.)