Proceedings of the Subcommittee on
Issue No. 20 - Evidence - October 24, 2018
OTTAWA, Wednesday, October 24, 2018
The Subcommittee on Veterans Affairs met this day at 11:59 a.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.
The Chair: Ladies and gentlemen, welcome to the Subcommittee on Veterans Affairs of the Senate Standing Committee on National Security and Defence. I would like to give my colleagues the opportunity to introduce themselves, starting on my right.
Senator Boniface: Gwen Boniface from Ontario.
Senator Doyle: Norman Doyle, Newfoundland and Labrador.
The Chair: I am Senator Jean-Guy Dagenais, Chair of the Subcommittee on Veterans Affairs. I would like to thank our witnesses, Gregg Battersby, Sarah Dobbin and Philippe Lucas, for appearing before the committee.
Today we are continuing our study on cannabis use for medical purposes by Canadian veterans. We’ll start with Mr. Lucas. Then the senators will ask questions. Go ahead, Mr. Lucas.
Philippe Lucas, Vice President, Global Patient Research and Access, Tilray: Thank you, Mr. Chair and honourable senators.
I will be presenting in English, but I am happy to take questions in French as a bilingual Canadian.
I wanted to start out by thanking you for the good work that you are doing. This is an important issue. We see so many patients currently affected by PTSD and other conditions, both police and military veterans, who seem to be benefiting from medical cannabis. I will be referring to slides that have been provided to you. They have been translated into French but without the slides and images, unfortunately. Whether or not you have them in front of you, the data I will share is focused on some of the research we are conducting on PTSD, as well as some of the patient research we are conducting.
Tilray is a global pioneer in medical cannabis research and access. Our products are currently available in five continents and 11 countries. We were the first GMP-certified medical cannabis production facility in North America.
We have been working to improve the lives of veterans through medical cannabis since we started. Right now Tilray serves over 500 veterans registered with Veterans Affairs Canada. We are the title sponsor of the Wounded Warrior Run in B.C., as well as the Highway of Heroes Bike Ride in British Columbia. We work closely with Wounded Warriors and other veteran organizations to try to improve the lives of those patients.
We have a number of VAC-specific services. We have reduced the cost of all of our cannabis to veterans in Canada, charging them just $8.50 a gram so they can access any cannabis products available on Tilray’s store. We have the VAC Bridge Program, which allows vets to order cannabis without charge while they are waiting for Veterans Affairs Canada to approve their cases. We have VAC specialists on staff who can work through approvals, denials and reimbursements with staff as well.
We are currently conducting a Phase II clinical trial on medical cannabis and post-traumatic stress disorder. It is taking place at the University of British Columbia and is the largest medical cannabis clinical trial to take place in Canada in the last 40 years and the first time medical cannabis is being studied for mental health condition in Canadian history. We will be launching a second site of that clinical trial in downtown Vancouver in the coming weeks, and we look forward to sharing the results of that study with this committee and Canadians across the nation.
We are conducting a number of observational studies as well, including a patient survey that we conducted in 2017 with 2,032 responses. It is the largest survey of Canadian patients to date. I would like to share some of the data from that survey. I will be sharing general data on patient patterns and views, but also data specific to our PTSD population so you can see how they differ from the patterns of use of the typical population.
This survey was sent out to over 16,000 Tilray patients. We had 2,032 complete responses, and we cut off the survey at that point. The average age of Tilray patients is about 40, but when it comes to patients suffering from PTSD, they are a bit older at 43. Overall, what you find if you look at primary conditions and symptoms of patients using medical cannabis in Canada is that pain is the number one indication or symptom cited by patients, followed closely by mental health conditions like stress, anxiety, depression and insomnia.
When we look at our data, about 80 per cent of Canadian patients are either using medical cannabis as a treatment for pain or for mental health. An interesting fact is that when we isolate the PTSD patients, those who say PTSD is their primary condition, we see that pain is no longer the primary condition. About 80 per cent of them cite that anxiety is their primary condition, 69 per cent cite stress and 68 per cent cite insomnia. So we see that with PTSD patients it is not so much pain relief they are looking for but relief from mental health conditions and symptoms like anxiety, stress, depression and insomnia.
When it comes to patient patterns of use, 75 per cent of Tilray patients use cannabis daily. Pain and mental health conditions are daily conditions with daily treatments. There is no real surprise in that. But when you look at PTSD patients, 85 per cent of those affected by PTSD use cannabis on a daily basis.
In terms of the average pattern of use, within our general patient population it is about 1.5 grams per day for those using flowers rather than extract cannabis. When we look at the PTSD sub-population, they use considerably more at 2.1 grams per day. With PTSD, probably because of the co-morbidity of a lot of different conditions — stress, anxiety, depression and in some cases chronic pain — they seem to be using more than the general patient population.
In terms of primary method of use, we find that 50 per cent of patients right now are PTSD patients using cannabis in non-smoke forms of ingestion. This is really good news, and it mirrors the shift we are seeing in the Canadian federal medical cannabis program away from the smoked ingestion of high THC products to the oral ingestion of high CBD products. This committee is probably familiar with CBD as being one of the primary constituents of the cannabis plant, but it is also non-impairing. It does not lead to impairment. We are seeing a shift towards higher CBD products in the oral ingestion of those products.
My special research area at Tilray and with the Canadian Institute for Substance Abuse Research is looking at the substitution of cannabis for not only prescription drugs but also alcohol, tobacco and otherwise. I would like to share data on that because I think it is relevant to this discussion that we don’t look at cannabis use in isolation. You always have to look at it holistically and the way that cannabis use affects the use of these other potentially more dangerous drugs.
I do not need to remind this committee that we are in the middle of an opioid overdose crisis in Canada. Reducing our dependence on opioids in the treatment of pain and other conditions is one of the ways we can reduce the potential negative public health and safety impacts associated with opioids.
When we ask our general patient population if they are substituting cannabis for prescription drugs, 69 per cent cite that they do, 44 per cent substitute for alcohol and 31 per cent for tobacco. But when it comes to PTSD patients, 75 per cent of them substitute cannabis for prescription drugs.
In fact, the primary drug substitution in our general population is opioids, at 35 per cent. That is closely followed by antidepressants, at 21 per cent. When we look at opioids in particular, out of 610 drug opioid mentions from this study, a full 60 per cent of those drug mentions, patients said they stopped using completely. They are not just reducing their use of opioids, but we’re seeing a total cessation of opioid use.
Interestingly enough, the PTSD population substitutes for all classes of mental health prescription drugs at a greater rate than other patients — antidepressants, muscle relaxants and sleep aids, benzodiazepines and antipsychotics. We see a greater level of substitutions from those suffering from PTSD than the general population. Knowing that they are suffering from PTSD and mental health conditions it may be obvious, but it is interesting to see it played out in this data.
In terms of alcohol substitution, we know that PTSD is all too often associated with the co-morbidity of drug dependence, including alcoholism. For PTSD patients, 44 per cent report stopping alcohol use completely simply by introducing medical cannabis into their course of care.
In conclusion, medical cannabis is primarily used in the treatment of chronic pain and mental health. Compared to other patients, those affected by PTSD are likely to be disabled. They are more likely to report use for anxiety, stress and depression. They are more likely to use cannabis daily, and they use more than the average patient. They are also more likely to use cannabis extract products and more likely to reduce their use of opioids, antidepressants and benzodiazepines.
According to data from Veterans Affairs Canada, the recent significant increase in the number of veterans using medical cannabis is paralleled by a nearly 43 per cent decrease in the number of veterans using benzodiazepines and a 31 per cent decrease in the number of veterans using opioids.
Tilray has put VAC-specific services in place to assist Canadian veterans. We are conducting clinical and observational research to better understand the harms and benefits of cannabis in the treatment of PTSD. We look forward to continuing to work with this committee and veterans to improve their health.
In closing, I talked to a few veteran patients, who are friends or colleagues, before coming here to see what they would like me to share with the committee today. They are very concerned about losing some of the cost coverage they are seeing right now. As you know, the cost coverage available to most veterans in Canada has been significantly reduced. They would like to see the taxation removed on medical cannabis in Canada and that the cost coverage they are currently getting stays in place or is increased enough to cover the use of veterans across the nation.
The Chair: Thank you, Mr. Lucas. Before I give the floor to Mr. Battersby, I would like to acknowledge the presence of Senator Wallin and Senator Richards, who have joined us.
The floor is yours, Mr. Battersby.
Gregg Battersby, Vice President, Commercial Strategy, Aphria: Thank you, senators, for the opportunity to be here today and make these brief introductory these remarks. I am the Vice President of Commercial Strategy at Aphria. I joined the company in March 2015 and have worked alongside our Leamington staff overseeing aspects of post-harvest operations, customer order fulfillment as well as supply chain. In my current position, I am responsible for aspects of the company’s commercial strategy, both domestic and international, business-to-business development and continued supply chain execution.
I am joined today by my colleague Sarah Dobbin, the director of Aphria’s medical patient care division. She joined Aphria in September 2014 and directly oversees patient care and patient outreach departments dealing directory with veterans. Unfortunately, Dr. Jonathan Simone, Aphria’s director of clinical research, who would have liked to be here, is travelling overseas and is unable to join us.
Aphria is a leading global cannabis company driven by an unrelenting commitment to our people, product quality and innovation. We are headquartered in Leamington, Ontario, which is the greenhouse capital of Canada. Founded in 2013, our deep experience in agriculture, innovation and regulatory environments has enabled us to set a standard for low-cost production of safe, clean and pure pharmaceutical-grade cannabis at scale. We are focused on untapped opportunities and backed by the latest technologies. This allows to us to bring breakthrough innovation to the global cannabis market and position us as one of Canada’s leaders in the space.
I would like to extend my congratulations and thanks to members of this committee and to the Senate of Canada for their commitment to the thorough review and consultation on passing and implementing the Cannabis Act.
Just like the government, Aphria believes and has strongly advocated that the creation of safe access to both medical and recreational cannabis in the market also needs a responsible approach.
As the launch of the recreational market has taken place, we need to acknowledge the diversity of opinion on how to handle cannabis in Canada. The debate over the best way forward is natural and welcome. The decisions that will be made now are critical to the success, sustainability and safety of the cannabis market in the future.
Canada’s medical cannabis regime is held up as a global model and our actions are being carefully observed. The real power of the medical market is its ability to legitimize cannabis for a broad cross-section of consumers while providing a solid rationale for further research and clinical studies. Organizations like the Canadian Nurses Association have argued in support of separate systems for years, citing concerns around access and an over-aggressive focus on recreational use over medical needs. We at Aphria fully support the idea of continuing clinical oversight as it makes the entire system safer and more efficient. Although we understand the challenge that medical cannabis can present for some physicians, the cannabis industry needs further research and more robust science on its impacts and effects.
We know that the work has been escalating as the recreational market approaches, and Aphria will continue to support independent research into the benefits and risks of cannabis from medical use.
Approximately one in 10 Canadians will suffer from post-traumatic stress disorder in their lifetime. The prevalence of this is approximately two-fold greater among Canadian veterans. There has been considerable pre-clinical research conducted over the last 20 years demonstrating the involvement of the endogenous cannabinoid system in the regulation of stress, anxiety and PTSD. Additionally, cannabinoids such as THC have been found to reduce anxiety-like behaviour and modulate the hormonal stress responses, which plays a critical role in brain plasticity and emotional memories are encoded, all of which are abhorrent to PTSD. There is a need for more quality research and controlled clinical trials.
Aphria has always been committed to providing superior patient care. Our team consistently goes above and beyond to ensure patients are comfortable every step of the way through the cannabis access process. Our proprietary 509-step “Seed to Sale Certified” quality promise is our commitment to protecting the health and safety of patients by ensuring we sell only clean, pure cannabis products 100 per cent of the time.
This past week Aphria announced, as did Tilray, that we will absorb the cost of excise tax on all of our medical products in an intermediate term. Our main objective in making that decision was to ensure continued access for patients through the transition to legalization.
Aphria works in full transparency with Health Canada, and we are committed to working alongside the government and regulators to ensure that all patients, regardless of their medical coverage, continue to receive the best possible treatment options. We will continue to support Canadians for fair access to medical marijuana and their work to remove all taxes from medical cannabis, both excise and sales tax.
Medical cannabis did not become legal in Canada purely as a means to broaden legalization. There will continue to be a medical purpose focused on patients in need, and we will be vigilant in protecting that market moving forward.
Through an established and distinct medical market, Canada can continue to lead in this space. It is essential that we ensure cannabis remains accessible to patients who want to explore it as a way of managing health challenges and that they have the support of the health care community.
I would like to thank the committee for inviting us to participate here today on behalf of Aphria, and I look forward to answering any questions.
The Chair: Thank you to our witnesses. Without further ado, we will move on to questions.
Senator Wallin: I will come at this from a slightly different angle and then we will back into some other questions later if we have time.
You three obviously know a lot about the effects of cannabis. We focus on vets and the military as well because a lot of the issues are about transition and work-related injuries. Do you think with the legalization of recreational cannabis that this will become an issue, knowing the effects of it? Might that become an issue for serving members in high-risk jobs? On the continuum, do you think that if they are using marijuana during their serving times, there may be less need later, and, therefore, are serving members a new target consumer group? Can you see where I am going with this?
Mr. Lucas: There is a lot of concern from employers across Canada, military and otherwise, about employees in safety-sensitive positions, in particular.
It is important to note that products are available out there, both in the medical and recreational market, that are high in CBD and low in THC and, therefore, are less likely to lead to impairment that may be an issue or otherwise.
It has been fascinating sitting back and watching how police and military organizations are handling legalization right now. We have seen a real schism in the way they have decided to do that. We have some police departments citing that officers can use it, but not within 28 days of being on duty, which, for all practical reasons, means never. In think that is a general misunderstanding of the data which suggests that cannabis may be detectable in different parts of the body — hair or otherwise — for 28 days. That is conflating the very clear data on impairment. The data on impairment is clear that when you are smoking or vaporizing cannabis, it is typically two to four hours, or let’s say six hours, at the onset. At Tilray, we warn our patients of that as a practice.
When it comes to oral ingestion, it is typically four to eight hours. After that, according to the data we have and research that has been conducted, patients are typically free of impairment.
We have other police departments, such as the Vancouver Police Department, that have opted to say, “Show up able to work the next day; are you capable of being on duty the next day?” They have adopted a similar policy as they have with alcohol, which is, basically, use your judgment and show up ready to work the next day.
Right now, policies that discriminate against cannabis versus alcohol and other potentially more dangerous drugs shift use towards those more dangerous drugs. I would be concerned about anything that encourages the use of alcohol or, in some cases, hard drugs; police and military folks know you can use a hard drug on a Friday night and have a clean urine test on a Monday morning. They are aware of this data as well, that it’s going to lead to more dangerous patterns of use. I am not particularly concerned, as a Canadian, if our military adopts a policy that would allow them to use a fairly benign substance like cannabis in terms of their choice of drug for impairment other than as a replacement for alcohol, which is the most criminogenic and dangerous substance we have in North America right now.
I just saw data in this morning’s Globe and Mail suggesting that we have more hospitalizations associated with alcohol use than all illicit substances combined. Certainly, we want to discourage the use of opioids and other drugs, so cannabis may be a safer alternative in considering the scope of your question.
Senator Wallin: Regarding serving members, you are saying you would be targeting them but not with the recreational use?
Mr. Lucas: To be clear, we don’t target anyone. We are very restricted by the federal government both in recreational and medical cannabis in terms of our marketing. We don’t do marketing; we do provide information when requested, but we certainly don’t do deliberate outreach to serving military, and none of that will change under legalization. We do support groups like Wounded Warrior Canada to provide them with information, outreach and education when requested.
Senator Wallin: Thank you.
Mr. Battersby: That was great, Dr. Lucas. You hit on pretty much every point.
I would like to reiterate I think it is a matter of understanding cannabis, its effects on the body, the amount of time it will remain in the system and finding alternate ways to measure impairment. Historically, alcohol has been measured by blood alcohol levels. The ability to do that is related to the fact that alcohol only stays in the system for 24 hours, whereas cannabis will stay in the system — but not have any level of impairment — for 28 days.
As Dr. Lucas said, from an impairment perspective, it only lasts anywhere from four to eight hours. Understanding that and finding alternate ways to work with it is a piece of this evolution of cannabis that everyone will need to work towards.
Regarding the second part of the question, Aphria is also not looking to target any particular community or subsection of the Canadian population more than any other. Cannabis is a product that works for many and doesn’t work for others. We are happy to serve any aspect of the Canadian population that will benefit from medical cannabis but do not support any type of impairment in the workplace.
Senator Wallin: You work more closely with veterans. I know this is a speculative question, but given the benefits that you are seeing with people who have PTSD using medical marijuana, it would make sense, then, in some situations that you would suggest that for serving members who are suffering from anxiety and stress while already on the job. I guess that is the area I want to focus on.
Sarah Dobbin, Director, Medical Division, Aphria: As Gregg mentioned, we are not specifically targeting —
Senator Wallin: No. I understand “targeting” may be a pejorative word. Do you see a field of opportunity not just corporately but for the serving member?
Ms. Dobbin: For that population?
Senator Wallin: Yes.
Ms. Dobbin: Potentially. I think the research needs to be there.
One comment in terms of impairment: A common thing we hear from our veteran population and a lot of Aphria patients is that they don’t want to be impaired. They will often call our call centre and ask, “What can I take that will not impair me? I want to be able to go to work and leave the house and be a functioning member of society.” That is why our CBD oil is an extremely popular product, along with other types of products where there isn’t going to be that impairment.
Mr. Lucas: The only thing I would add to that is we are seeing more and more in Canada and the U.S. active military personnel who are having to leave the force because of PTSD and other mental health conditions. If the use of medical cannabis while they are still in the force would help reduce their need to leave active duty, that might be beneficial overall.
Obviously, our goal is to keep people in the workforce, whether it is military or otherwise. We see that about 60 per cent of our patients at Tilray are still working full or part time, and they report regularly that cannabis, rather than forcing them to stay home, allows them to lead a more active life.
If we could see the same thing within military culture, if it allows those who want to commit and have committed their lives to working in the military to stay on longer rather than having to leave the force to seek treatment, that would be a positive outcome for Canadians.
Senator Boniface: Thank you very much. This is an interesting topic to me for a number of reasons.
Mr. Lucas, I am interested in the study that you are doing. I worry a bit with companies doing studies and how independent the research is because, as you know, the jury is still out on how effective it is. We know what people tell us, but if you were looking at long-term health, what would it say? There is not a lot of research because we have had an illegal business for so long. I appreciate you are doing a study on it, but I am also interested in how you do a study that somehow serves your corporate interests — and that is absolutely valid — but, at the same time, has a public interest. I would hate to confuse the two.
Mr. Lucas: I completely agree. That is a goal of ours.
I have been working on medical cannabis for over 20 years. I started out as a patient and then a patient advocate, and over the last 15 years I have been a medical cannabis researcher with a real focus on patient patterns of use and cannabis substitution effect.
So much of what we know about medical cannabis right now, whether it be its use in the treatment of pediatric epilepsy, chronic pain or PTSD, for examples, we first hear about it through the patient experience, and then science races to catch up.
Tilray recently concluded a successful study at SickKids Hospital looking at pediatric epilepsy. We would not have known that high-CBD extract was useful in pediatric epilepsy had patients not shared that experience first, and we designed a study to test that more objectively.
That has certainly been the case with PTSD. In my work as a long-term patient provider and advocate, I started hearing about the use of medical cannabis and PTSD at the end of the 1990s, around 2000, when First Nations populations started using medical cannabis and reporting that they found it useful in the treatment of PTSD.
Our study with UBC, I should note, is a Phase II clinical trial. It has gone through Health Canada ethics review and approval and UBC ethics and approval in order to guarantee that it’s not only a safe study for the participants, or relatively safe, and that we’re introducing a new drug treatment, but also that it meets ethical considerations around the independence of the study.
The study is taking place at UBC Okanagan. No Tilray staff are directly involved in the administration of that study. We are producing and providing three different preparations that are being used in that study — a 10 per cent THC cannabis preparation; a 10 per cent THC, 10 per cent CBD cannabis preparation; and a placebo preparation — in order to see if the addition of CBD changes the treatment response for those patients. We’re tracking detailed outcomes, such as the CAPS score, which is the main way to assess PTSD severity, as well as sleep measures and quality of life measures, in order to see if it’s improving outcomes or not.
We don’t know the outcomes of that study yet; it’s still under way. But like any study, there’s equipoise, and it may be that it’s not helpful or it may be that it turns out to be helpful. We’re just eager to gather the data and to share that publicly through publications in academic journals.
We do our best, because we’re aware that there’s concern not just with cannabis companies but with pharmaceutical companies being involved in this kind of research. The fact and the truth is that we would love for the federal government to undertake this research. We’d love for Veterans Affairs Canada to undertake this kind of research. They’re not currently funding — or certainly they weren’t three years ago when we started the study — this kind of study. So we felt the need to go ahead and do this because it was such an open question, whether it was useful in the treatment of PTSD.
I understand now that there may be a government-directed study very similar to ours that’s under way and under design. The folks on this panel may know more about this than I do. But I can assure you that our goal right now is just to gather this data and to share it in order to better inform treatment options for physicians and patients who may be considering this.
Senator Boniface: I want to follow up and make sure I am correct on some information you provided. I think you said for your regular patients, 1.5 grams per day; for people suffering from PTSD, 2.1. I assume that’s veterans and others who may suffer from it.
Mr. Lucas: That’s right.
Senator Boniface: As you would be well aware, Veterans Affairs has gone through a process whereby 1.1 grams were allowed, and then to 3 grams. We’ve heard a fair bit of evidence around this issue in terms of whether or not that’s adequate. But your averaging would say that 3 grams is actually sufficient generally?
Mr. Lucas: About 80 per cent of our patients, including PTSD patients, use 3 grams or less per day. Slightly less than 20 per cent will use more than that.
There is an outlier there. There is a percentage of folks for whom the Veterans Affairs program may not cover. There is an exemption process with Veterans Affairs. Vets have reported that it can be tricky sometimes to find a psychiatrist or pain specialist who is able to testify and write in an application for that exception process. But we do find that that 3 grams a day covers about 80 per cent of veterans in Canada who are using cannabis for medical purposes. Our concern, of course, continues to be for the 20 per cent who may fall outside of that number.
Senator Boniface: I have a small clarification. I’m going back to Mr. Battersby’s reference to impairment, an issue I know fairly well as the sponsor of Bill C-46. If you take 3 grams versus 10 grams a day, there’s a difference in level of potential impairment.
Mr. Lucas: I think there’s no doubt there’s a big difference in the blood plasma levels of THC, if you’re using THC-based products. If you’re using CBD products, it may be less relevant in terms of the actual dosage.
The Chair: As you know, recreational cannabis was legalized last week. What might be the impact of recreational cannabis use on medical cannabis? Could the legalization of recreational cannabis have an impact on the price of medical cannabis?
Mr. Battersby: Again, only being seven days in, we have not seen a significant change in consumption levels among our medical patient population as of yet.
Sarah can likely speak a little more to the patient onboarding side and whether we’ve seen a change there, but much of our patient population is using on the oil side, and our flagship product is a high CBD product. To date, we have not seen any faltering in the level of consumption among medical patients on the CBD side, as well as the THC side. So it gives us relative certainty that the patients registered with Aphria are using for true medical reasons and would rather consume under the care and supervision of their doctor than going to a recreational store and purchasing.
Have we seen any change in registration?
Ms. Dobbin: You’re right; we haven’t. But it’s important to point out that had we not made the decision, like Tilray and other licensed producers, to absorb the excise tax, we would have seen that difference just from an access perspective. If a patient can go down the street and purchase a product that, in their mind, they deem to be similar to something they’re going to order from us, which is going to be more steps in that process, that may have been shipped a little more immediately. But because we are absorbing that excise tax in the immediate term, we didn’t see that. We heard from patients that that was extremely important to them in their decision of whether to stay with the medical stream or the recreational stream.
Mr. Lucas: I would add that within our federal medical cannabis program we have about 300,000 Canadians signed up. When you poll Canadians to find out if they’re using medical cannabis, about a million Canadians claim to use cannabis for medical purposes. That means about one third of those are within the federal program, and two thirds are accessing cannabis outside of the federal program.
Depending on which survey we look at in the last six months, between 10 and 20 per cent of Canadians are using recreational cannabis on a regular basis. So you shift from 2 to 4 per cent of the adult population using it for medical purposes, compared to 10 or 20 per cent of the population using it for recreational purposes. So we have far more people using it recreationally than we do medically, of course.
However, I think when we’re talking about the patients covered by Veterans Affairs Canada, there’s obviously a big disincentive for them to shift to the recreational market because they won’t get cost coverage through the LCBO or the Liquor Distribution Branch in B.C. or some of the outlets. So I don’t think we’re going to see a significant migration away from the medical program to the recreational program for those covered by Veterans Affairs Canada because they wouldn’t benefit from those discounts.
I also think that when we’ve done surveying that veterans population, 97 per cent cite that they would continue to take part in the federal medical cannabis program, the ACMPR.
I think that suggests a pretty high level of satisfaction overall with the current federal medical cannabis program. I’m not sure we can get 97 per cent of Canadians to agree about Fund A Dog or that ice cream is tasty on a hot day. So that’s a high level of support that we’re seeing for the current federal program within that population.
The Chair: Before I give the floor to my colleagues, if you had a recommendation for our report, what would it be? What actions should the federal government focus on regarding cannabis use for medical purposes by veterans? Would you have any recommendations for us?
Mr. Battersby: I think largely we aren’t here today to comment on government policies or VAC policies on cannabis use and coverage for Veterans Affairs.
If there were one thing we would want to look at with the policies we put in place and the restrictions we put on coverage, it is making sure we’re not restricting our veteran community from purchasing certain products. There’s both a 3-gram per day cap as well as an $8.50 cap on a per gram basis for cost. Many products in the market are above $8.50 a gram, particularly around oil products and some of the capsule products being introduced, which I think Dr. Lucas would agree may be a more controlled dosage. Many of those are at an average price slightly above the $8.50. I would caution to at least look at it. That would be the one recommendation.
Mr. Lucas: Thank you so much for the opportunity to provide this commentary.
I would strongly support more research on the use of medical cannabis, not just on PTSD but on other mental health conditions. We see such a high level of use to treat anxiety, depression and insomnia, and yet we’ve got a counter-discourse suggesting that cannabis may be more challenging for people with psychoses or schizophrenia and that that may be problematic. This is a really important area of research that we need to commit more time and energy to examine.
Tilray is doing some work on anxiety right now, and we’ll be announcing further studies on anxiety.
I would also say cite that in my 20 years of working with medical cannabis patients, cost has always been an obstacle to access. I want to really commend the federal government, Veterans Affairs, for providing cost coverage to Canadian, police, military and correction agency veterans; but I would also suggest that for those still facing an obstacle, whether it be accessing extracts, as Mr. Battersby has suggested, or otherwise, we want to make sure that we don’t put such significant limits on it that it leads to less access for veterans in Canada to the medicine that might be beneficial to them.
Finally, I would suggest, in regard to the earlier discussion that we had, for those who are still on active duty — and I don’t say this for the police and military veterans — I would think that if we have policies around alcohol in Canada, we should not have policies that treat cannabis more harshly than alcohol on any objective measure, whether it be violent crime, domestic violence, homicide or suicide. Alcohol is far more problematic than cannabis.
I’m concerned when we start treating cannabis differentially compared to alcohol policies for those in active military service. If we’re going to put in place policies on the recreational use of cannabis, I would suggest that the policy should mirror an alcohol-based policy and not encourage the use of alcohol and deter the use of cannabis as an alternative. I don’t think that is in keeping with the evidence or with the public health goals of the military or Canadian public health as a whole.
Senator Doyle: Where does a veteran turn to for advice on which product he should use and how it should be used? I’m sure there’s a variety of different ways to use it and how one should use. First, does he go to a doctor to talk about it? Does he talk to a producer? What are the steps that he has to take?
Mr. Battersby: The doctor should always be the first line and the main point of consultation for any patient, veteran or civilian. I would say the doctor has the most influence over a patient and veteran and how they consume.
That said, when the patient registers with a licensed producer, we also have patient care services — and Sarah can comment on them further — that will help counsel and answer any questions that the veteran may have that weren’t otherwise answered by their physician or that their physician may have directed them to the patient care team on.
Ms. Dobbin: A question could be, “My doctor prescribed a maximum of 6 per cent THC; which products of yours fall within that spec?” We call every Aphria patient, regardless of whether they are a veteran or not, and make sure they understand what they were prescribed and what that looks like. Since there are so many different licensed producers, our high CBD oil would be called something different from Tilray’s high CBD oil. We want to make sure they understand exactly what they were prescribed.
Senator Doyle: In your opinion, would the medical community have a lot of expertise in this area? It’s pretty new. In medical school, you won’t be told all about what kind of cannabis to use. What kind of process has the medical community gone through to gain access to all of the expertise that’s obviously needed?
Mr. Lucas: I’m extremely pleased to say that over the last 10 or 15 years we have seen more and more members of the medical community self-inform about the medical use of cannabis. This is typically prompted by patients requesting access and feeling that they need to educate themselves on this.
There are now major medical schools in Canada actually incorporating into their course work information on the endocannabinoid system, on the use of cannabis and cannabinoids. UBC is a good example of one of them that’s taking place right now.
More and more, organizations like Tilray and Aphria are also doing CME, Continuing Medical Education programs, taught by physicians, for physicians, to walk them through some of the pharmaco-kinetics and pharmaco-dynamics of medical cannabis and some of the treatment options.
I also want to share that in the past few years I have been invited to do presentations at the CIMVHR conference, the Canadian Institute of Military Veterans Health Research, to share some of our findings on the use of cannabis in the treatment of mental health and PTSD, along with other academics around Canada. There’s an active seeking of this information by police and military veteran groups, and we’re happy to provide that when possible.
In closing, it’s clear that much more needs to be done, that physicians need to be better informed. About this time last year, the Health Canada program, according to Health Canada, was growing by 10 per cent on a month-to-month basis in the number of patients in the program, but it was growing by 12 per cent month-to-month in the number of prescribing physicians. So more physicians are coming on board and educating themselves, but there’s still a lot of work to be done in that area.
Senator Doyle: Thank you.
Senator Wallin: In checking one point, you said in your study, Mr. Lucas, that you are putting three products out, one of which is a placebo. Is there a CBD only?
Mr. Lucas: There is no CBD-only arm, for the simple reason at the time we started this study about three years ago, Tilray did not have a CBD product. The reason we’re using whole flower cannabis instead of extract products was when we started the study, Health Canada had not provided us with permission to provide oils or to manufacture oils. That has happened in the last couple of years.
If we were to launch the study today, we would probably be using an oil-based extract and it would have a pure CBD arm.
Our recent pediatric epilepsy study used a very low THC, very high CBD extract at 2 milligrams of THC, 100 milligrams of CBD.
These products are available now and are typically a starting point for when patients are new to medical cannabis. They are certainly what we recommend when patients call in and say they’re new to this.
Senator Wallin: Is anybody doing a CBD study anywhere?
Mr. Lucas: There’s a U.S. study similar to the one we’re doing right now that’s taking place in a couple of jurisdictions, funded through a grant from the State of Colorado. I believe they have a high CBD, low THC arm as part of that study. It’s very low THC. A little THC is involved because it’s a smoke cannabis study. Ours is a vaporized cannabis study.
That’s what’s available right now. I’m not aware of anyone specifically looking just at CBD in the treatment of PTSD.
Senator Wallin: I came in late, so I apologize. You may have explained this or it may be totally inappropriate.
You mentioned, Mr. Lucas, that you were a patient. You’ve gone through the full range of this. Could you explain or talk about your own experience?
Mr. Lucas: I’m absolutely happy to.
In 1995, I was diagnosed with hepatitis C that I’d gotten through the tainted blood system in Ontario when I was 12 years old as a result of a splenectomy. At the time there were no treatment options. Even the forthcoming treatment options that were there were not available.
I used medical cannabis initially to reduce my use and then to stop my use of alcohol and tobacco. It’s the only thing my doctor could tell me to do at the time because there was no treatment available.
I found that it was helpful, but I also found it helpful in dealing with my symptoms of hep C, including localized pain, inflammation. It was stimulating my appetite and reducing nausea as well.
I’m grateful to say that about four years ago I went through what at the time was an experimental hep C treatment, a combination treatment, and was cured of hepatitis C.
I just got shivers.
It’s remarkable when we can actually find a cure for an entire disease group like that. For all hep C patients across Canada and the world, it’s been a remarkable development.
Senator Wallin: Yes. I’m working on a blood donor bill as well, so I know all about it. Thank you for that.
Senator Boniface: Being from B.C., you flagged the opioid crisis that’s across the country. One of my concerns in terms of this is the lack of research and lack of knowledge that doctors had, and the overprescribing on the opioid crisis is the root of the issue.
My question concerns the access for veterans and others. You indicated 2.5 grams a day for PTSD. Are there any studies that would tell us how long that would be done and at what point people move from taking it medicinally to not using it?
Mr. Lucas: What a great question. I mentioned 2.1 grams a day was the use by patients and 1.5 was the average.
A couple of things are really interesting with medical cannabis. Patients tend to develop a tolerance to the side effects of medical cannabis, including impairment, by the way. So even at much higher dosages than typically would be used in a recreational user, patients report they don’t get impairment. But the red eyes, the tachycardia, all of this they seem to develop a tolerance for over time but not to the actual therapeutic effects of it.
I have data to support that. I’m the primary investigator in the largest longitudinal study of medical cannabis patients to date. We have 1,900 patients at 20 clinics in five provinces across Canada. What we see in the first six months of use, from baseline to six months — because we do data gathering at baseline, one month, three months, six months — is that the average use does not increase, particularly with naive patients. Once they find that proper dosage, it doesn’t seem to go up the way it does with opioids, which is definitely an encouraging sign.
When they can stop using it is a different question because, ultimately, medical cannabis is not curative for PTSD or other mental health conditions. It tends to reduce symptomatology, and our hope and goal is that by reducing symptoms and increasing function and quality of life, those patients can then seek treatments, whether it be through standard psychotherapy or potentially other behavioural treatments or even other pharmaceutical treatments that can then lead to a longer-lasting cure.
Really, when we’re talking about the use of medical cannabis and PTSD, we’re talking about reducing symptomatology such as hyper-vigilance, insomnia, the horrible nightmares that accompany PTSD for far too many sufferers, and moving towards a more regular, higher quality of life.
Senator Boniface: I have a quick comment. The symptoms you just described are also similar symptoms to how people justify the initial prescribing of opioids. I’m very interested in the longitudinal study. I think what we all want at the end of the day is for people to be healthy. With regard to how they get there, we shouldn’t be creating a secondary difficulty for them in the process.
Thank you for your comments.
The Chair: Before closing our discussion, I have three questions. We know that those who have invested in the new cannabis production companies over the past year seem to have made a fortune on the stock market. Prices are very much on the rise, while Tilray’s share price has dropped from $300 to $115 on the NASDAQ.
Should this be seen as a movement that could lead medical cannabis users to turn to recreational cannabis?
Mr. Battersby: As I stated earlier, we have not seen that trend thus far, but it is obviously a topic that has been discussed and is something that we will be closely monitoring and watching those trends and what happens throughout the next month, three months, 12 months.
It’s a tough question to answer, but I think those patients who decide to transition out of the medical regime into a more recreational regime may do so because of access to physicians. Possibly they’re just doing it out of ease of access and they don’t have access to a prescribing physician anymore, so they will try more simple channels to get through.
As I stated earlier, approximately 300,000 Canadians who are prescribed under the medical regime are largely there because they prefer to be treated under the supervision of their physicians. From an economic perspective, I don’t think a downturn in medical consumption is a huge risk for our companies. We, obviously, welcome the transition into legalization of cannabis as well.
Mr. Lucas: Well said. What I would add is that we really don’t know what’s going to happen in Canada, but we do get good indications by looking at the U.S. experience. What we see in those medical cannabis states in the U.S. that have since turned to recreational cannabis states — I think about Colorado, Washington and Oregon, primarily, and we’ll find out more about California because legalization is new there — is that there was an initial drop-off in medical cannabis use that lasted a couple of months as people explored the storefront access available through recreational cannabis, and then a sharp increase in medical cannabis registrations after that. That has been attributed to a destigmatization that happens when we legalize this substance overall, not just for a subset of patients.
I think a few months from now, when physicians see a patient regarding medical cannabis, the fact it’s available at neighbourhood corner stores or LCBOs or liquor distribution boards will mean that that physician can have more faith that that patient truly is a medical cannabis patient, because there are other alternatives to legal access.
I think we’re actually going to see an increase now that we’ve removed some of the stigma around medical cannabis use through the legalization of recreational cannabis.
I’d also add that 2019 will likely see the real expansion of medical cannabis access to pharmacies, and nothing will do more to destigmatize and normalize medical cannabis access than when we start treating it like all other prescription drugs. That’s going to really increase the confidence of pharmacists, physicians and patients in considering this as a treatment option, because it will be treated like every other medication.
Finally, I’d suggest that we’re going to look back at 2018 and see this as the year that private payer coverage for medical cannabis really started out and became more available outside of the VAC program. So we see now Sun Life, Great-West Life, Green Shield offering medical cannabis coverage to large group plans. While it’s still a small percentage of the Canadian patient population, less than 10 per cent that are getting coverage, that is growing at a rapidly expanding rate.
I see this as a precursor to provincial coverage over the next five or six years, when the provinces do the economic analysis and see there are actually cost savings involved in covering medical cannabis versus other prescription drugs, particularly in terms of the reductions in doctor visits, ER visits and hospitalizations that medical cannabis patients face compared to non-medical-cannabis-using patients.
So I do think we will see an increase in the medical cannabis program as it grows, not just in Canada but internationally as well.
The Chair: Before you leave, Mr. Lucas, are you able to tell us what proportion of patients will find sufficient relief when they use cannabis without impairing their faculties?
Mr. Lucas: The goal is to find a dosage window that allows you relief of symptoms and conditions without impairment.
Those patients who continue to use medical cannabis — those patients who are part of our programs, as opposed to those who may have dropped out — have been able to do that. They have been able to find a dosage window that improves their quality of life and functionality without impairment being part of that equation.
As Mr. Battersby pointed out, this is not a treatment option for all patients and for all conditions across Canada. I would never suggest that by any means. But for those patients who benefit from its use, it can really be life-changing. In some ways it can be life changing in small, incremental ways. It can improve sleep and the ability to eat and digest food when it comes to GI issues like Crohn’s, colitis, IBS and IBD. In other cases, it’s completely life-changing, such as pediatric patients who might suffer from 100 seizures a day that go down to zero or a few seizures a month. In those cases, it is definitely life-changing.
Our PTSD patients report to us the tragedy of their conditions before they used medical cannabis and the significant improvement in functioning and overall quality of life that they gain from this. It is quite amazing when it comes, particularly, to PTSD patients. You are not just helping that patient. You are helping that patient’s spouse, child, or their mothers or fathers as well, because PTSD is not an isolated incident in that it affects all of the relationships around them. If it helps improve those conditions, then we would expect patients to stay on it and continue to seek it. If their condition is not improving, then we would expect them to move on and try other treatments.
The Chair: To what extent has the reduction in the amount of cannabis reimbursed to veterans changed veterans’ use patterns?
Mr. Lucas: I’m so sorry. Could you please repeat the question?
The Chair: In fact, the amounts of cannabis that are reimbursed to veterans have been reduced. Has this led to a reduction in consumption?
Mr. Lucas: There was a reduction in consumption for a group of patients. As you know, patients with post-traumatic stress disorder consumed between 7 and 10 grams per day. We aren’t sure if it was the amount they were consuming, but it was the amount they were ordering. With the changes, for the most part, this reduced the amount they could order. We cannot know if this will really change the amount consumed. Some may have to buy their cannabis from other sources or pay out of their own pockets for cannabis from other sources. We don’t know exactly if they consume cannabis other than what they order from licensed producers such as Tilray and Aphria. As I mentioned earlier, about 80 per cent of patients in Canada, including veterans, seem to consume three grams or less. However, for the 20 per cent who need more, we can’t know where they get their cannabis from and how much they use.
The Chair: No one else has any questions, so I would like to thank all the witnesses for their testimonies.
(The committee adjourned.)