Mr. Chair, ladies and gentlemen of the committee, my name is Debbie Lowther. I am the chair and co-founder of VETS Canada. Thank you for the invitation to appear before you today, and thank you for undertaking this very important study of homeless veterans. It is a privilege for me to be here to share some of our insight as it pertains to the topic.
VETS Canada is a national not-for-profit organization with an aim to provide assistance to veterans of the Canadian Armed Forces and RCMP who are homeless or who are at risk of becoming homeless. We were founded in 2010 and are located across the country, with hundreds of dedicated volunteers who directly assist veterans. With a headquarters in Halifax and our volunteers across the country, we have responded to over 6,000 requests for assistance from veterans and their families from coast to coast, 24 hours a day, seven days a week, including holidays. We are currently taking between 200 and 300 requests for assistance each month.
Those requests come to us in a variety of ways, through our 1-888 phone line, our website or social media platforms, and most recently through our newly opened veterans drop-in and support centre here in Ottawa as well as our recently announced veterans support centre in Edmonton. Some of those referrals are from other organizations or agencies. Approximately half of our referrals each month come from Veterans Affairs Canada case managers.
Since 2010 we've certainly learned a great deal about veteran homelessness. We've learned that there is a uniqueness to it that sets it apart from civilian homelessness. To understand veteran homelessness, one must first understand that serving in the military is not just a job or a career; it is a culture all on its own. When you serve in the military, it becomes your identity. Military members are those who are willing to lay down their lives in service to their country, and in order to do so, they develop incredible bonds with their fellow military members.
We know that there are many pathways into homeless, such as poverty, lack of affordable housing, job loss or instability, mental illness and addictions, physical health problems, family or domestic violence, and family or marital breakdown. What sets veterans apart is that they not only deal with all of these same issues but they also struggle with their transition from military to civilian life. I talked about the military being a unique culture. Well, now the veteran is trying to adapt to a new civilian culture, feeling as though they have lost their identity and doing so without the social support network that was always so important.
Our organization conducted a very informal research project. We surveyed a small sampling of veterans we had assisted. We were surprised to hear that the majority of veterans surveyed identified a lack of social support as a bigger issue than health concerns or financial issues.
That survey also told us that the first episode of homelessness did not occur for an average of 11 years post-release. The average length of service was less than 10 years, so there was no annuity in place, and the ranks were sergeant and below.
Since you are the Standing Committee on Veterans Affairs and since half of our referrals come from the department each month, I will talk about our experience as it pertains to our efforts to assist homeless veterans in collaboration with the department.
In 2014 we were awarded a contract by Veterans Affairs Canada, making us their service providers in the field of homeless and in-crisis veteran outreach. That contract ended at the end of September of this year and was not renewed or extended. We were told in June that this would be the case, but we were told to apply for the new veteran and family well-being fund. We were told on September 28 that our application had been approved.
To be clear, we are grateful to the government for the new funding, but the funding that we asked for as part of this new source of funding, based on an increasing need in this area, was only partially approved by the department. We received only half of what we asked for, half of what we need to do our work assisting veterans and their families. As I said, we are grateful for the funding but disappointed that the department has determined that this issue of homeless veterans does not warrant a dedicated service provider.
On June 7 this year, Veterans Affairs held a round table on veteran homelessness which included people from over 60 organizations. The group included researchers, staff from organizations that serve veterans but not specifically homeless veterans, as well as staff from various shelters across the country. VETS Canada, the Royal Canadian Legion, and maybe two or three other organizations were, honestly, the only groups who could say that they occupy the homeless veterans space specifically. Many of the people who were in my breakout group were very frank about the the fact that they were there to learn, because while they may have veterans accessing their shelters or services, they did not have an understanding of the uniqueness of veteran homelessness.
One of the outcomes of this round table was an interactive map, featured on the Veterans Affairs website, with links to over 100 organizations across the country. Most of those organizations are shelters. I count only eight veteran-specific organizations, and of those, one is an organization that brings groups together to network and raise awareness. It does not provide a service to veterans. Two are organizations that are in the process of building housing for homeless veterans, but at this point that housing does not exist.
The interactive map has the Royal Canadian Legion located in Ontario only and VETS Canada located in Halifax only, when we are both national organizations.
My intention here is not to sound critical or negative, but this has become a very crowded landscape and more than anything, homeless veterans, like all homeless people, want to receive help from a credible organization that is going to deliver on what they say they can do. They're not interested in dealing with a connecting agency or a middleman that is just going to refer them to someone else.
We do not naively think that one organization can solve this issue. We realize it takes a collaborative effort, but we also know that a veteran is more likely to accept help from someone who speaks their language, who understands their culture and who can provide immediate support.
In closing, VETS Canada will continue to do its work, regardless of the support we receive or the challenges we face. Our commitment remains strong and resolute, that being to provide emergency support to veterans and their families in need, 24 hours a day, seven days a week, from coast to coast.
Mr. Chair, thank you.
I look forward to your questions.
Honourable Chairman and members of the parliamentary Standing Committee on Veterans Affairs, thank you for inviting the Royal Canadian Legion to address you today on your study, which will focus mainly on the challenges faced by homeless veterans, the causes that lead to their homelessness, and Veterans Affairs Canada's efforts to address this issue.
On behalf of our dominion president, Comrade Tom Irvine, and our members, I am the director of veterans services at the national headquarters of the Legion here in Ottawa. With me today is comrade Dave Gordon, the homeless veterans representative on our national veterans service and seniors committee.
I'd like to start with some important background that I think is a crucial backdrop to addressing possible solutions. While in the military, individuals are indoctrinated into a regimented system, believing that this system will always look after them. They accept the military culture of teamwork, and rely heavily on that team for support. It becomes part of their very fabric. For some, leaving that lifestyle is a difficult process. Many never truly leave the military culture.
Many factors can impede a smooth transition from military life. Each individual undergoing transition has unique challenges. Military life provides a secure and stable financial environment even when operational deployments are dangerous. Service personnel and their families grow with the military culture and have relatively comfortable lives. In essence, the military is part of their extended family. The bond is strong, and it is hard, if not impossible, for some to break.
The range of issues today, from mental health to severe disability, also complicates the transition process. Mental health is often an unseen disability. Acceptance of the problem, with programs designed to benefit those suffering, has yet to be fully realized. Stigma is a major factor, although great strides have been made to overcome it. Often, multiple disabilities combine to create very complicated cases involving not only physical but also mental health issues. Long-term treatments can be required before someone can achieve their new normal.
The question we need to consider is this: What is the best course of action to help such individuals, people who can ultimately slide down that slippery slope towards homelessness? Regardless of the stage of service—before, during, or after—it is important that all personnel understand the consequences of their service and have confidence in the system. Frankly, it starts here, with the support of the government that ultimately makes the decision to place Canadian service personnel in harm's way. Personnel have to understand and truly know that the system they have been indoctrinated into will look after them and their families without fail.
I'd like to share a little more perspective. Even in normal, non-injury transitional situations, I have seen people who have difficulty leaving the sanctuary of military life. Everything was provided for them. Now they are left to deal with what feels like a foreign world to arrange health care and other services that were once provided by the military. For those who are transitioning with more complex issues, extra care is needed. Knowledge and communication are paramount throughout a military career so that those who need assistance know how to access it. I must emphasize again that whether issues are apparent or not, people who leave service need to understand and trust that support will be there when and if needed.
The Canadian Armed Forces stated that it would revamp the complete transitional process and ensure that only those who are fit to be transitioned are. Close coordination between the Department of National Defence and Veterans Affairs Canada are essential to ensure that no one falls through the cracks and that continuous support is provided throughout. The ultimate aim is that a service person and their family can smoothly reintegrate into life outside the military. This will be a much-needed and positive step.
I mention all of this because it is crucial to know about a veteran's state of being during the transition period in terms of understanding the fundamental factors that can contribute to homelessness.
The Royal Canadian Legion has learned a lot about homelessness over the years, and I'd like to provide a basic overview. We help veterans and their families members get off the streets and turn their lives around through national and provincial programs. We offer financial assistance and other supports for homeless veterans and for those who are at risk of homelessness.
In 2012 the Legion established a national homeless veterans program called Leave the Streets Behind. It was based on the groundbreaking work of Ontario Command a few years earlier. The program's mission is to reach out to homeless or near-homeless veterans by providing immediate financial assistance and support when and where needed. It also connects them with the appropriate social and community services to establish a long-term solution to meet their needs.
We committed $500,000 towards combatting homelessness in 2012. We are still working towards the goal of ensuring that every Legion provincial command establishes a homeless veterans program tailored to meet their unique regional and community needs.
Ontario's was the first provincial command to develop and offer the Leave the Streets Behind program in November 2009. Through their efforts, the Legion established a network of support through Veterans Affairs and various shelters across the province to provide transition assistance to homeless veterans. Through the generosity of Ontario Command branches and the Legion's ladies auxiliaries in the region, they have disbursed over $2 million. They have a partnership with Mainstay Housing in Toronto and are supporting three locations in Toronto: Parliament Street, Bathurst Street and 10 apartments in the Pan Am village. To date, Ontario Command has assisted 667 homeless veterans in 139 communities in Ontario, and that includes 62 female homeless veterans.
B.C./Yukon Command provides financial support for Veterans Manor in Vancouver's east side and for Cockrell House in Victoria, a transition house that is presently full. There are nine rooms there, and they are constantly full.
Alberta/Northwest Territories Command operated a food bank for over 20 years and today works directly with the Calgary Food Bank to assist many veterans in the community. The command is also engaged with first responders, social services and Veterans Affairs Canada in identifying and assisting homeless veterans. Although they do not keep detailed statistics, their estimate for providing emergency shelter for veterans in the past three years would be over 60 veterans and families. The number of veterans who they have helped with rent to ensure they do not become homeless would be more than double that number.
Nova Scotia/Nunavut Command launched the veterans outreach program, bringing together community resources and establishing partnerships to provide proactive assistance to homeless veterans.
Those are four key examples of concerted work in the area of homelessness within our commands. Not all commands collect statistics on homeless veterans with the same detail as the Ontario Command, but all branches and commands have assisted homeless veterans in various ways.
I can tell you that the overarching message is clear: The system of helping homeless veterans is not one size fits all. We all know that the reasons for homelessness are complex and are the result of the combination of a number of factors: mental illness, substance abuse, poverty, a poor labour market, a decrease in affordable housing and catastrophic events such as family violence or family breakup. We have learned that giving someone a roof does not fix the problems that pushed him or her into homelessness in the first place. We first ensure that they have secure shelter and work with them to determine the problem and then the best way to solve the root of the problem.
We have heard, for example, that some homeless veterans do not actually want the social responsibility of having and maintaining accommodations. While there is no single solution, we felt that we had to start somewhere. Recognizing the need for a coordinated national strategy to address the issues facing homeless veterans, the Legion coordinated and hosted a homeless veterans forum in April 2014. This meeting brought together national organizations working with homeless individuals, but with a key focus on veterans. It was determined that further efforts to address veterans homelessness could benefit from establishing a smaller working group to define the best path to combat veteran homelessness.
The Royal Canadian Legion Veterans Homelessness Advisory Committee was formed and is chaired by our dominion president. There are representatives from Veterans Affairs Canada, CAF, the Salvation Army, the Good Shepherd Ministries, the Mental Health Commission of Canada, ESDC, the Ontario provincial command of the Legion and VETS Canada.
Together, we are gaining a better understanding of the problem and are networking and discussing solutions. The forum and our working group have helped identify priority areas and knowledge gaps. Let me name the key ones: transition barriers; outreach and communication; services and programs; and, accessibility and coordination of efforts.
Why do we have so many homeless veterans? Consultations like the ones I've just described have told us why. Now we need to focus on solutions.
Veterans Affairs Canada is the department responsible for looking after our veterans, so I ask now, why doesn't Canada have a national strategy on tackling veterans homelessness? In 2016 we were briefed on a VAC homelessness strategy and action plan in the works that would be veteran-centric, evidence informed and outcome based. We were told that it would enable VAC and partners to better find and assist homeless veterans and veterans in crisis and prevent veteran homelessness. To date, we have seen no sign of progress.
Comprehensive case management to include assistance in finding housing and connections to supports within the community are required now.
A life skills program to provide learning and networking opportunities for veterans is needed now. Veterans served and sacrificed for our country, and it is our duty to now stand for them and ensure that they have access to the care and support they need.
On behalf of all of our veterans, I ask, when can we expect a national strategy to combat veteran homelessness?
Chairman, we thank you for the opportunity to make this presentation, and we await your questions.
Thank you, Chair, and thank you so much, Mr. Gordon, Mr. McInnis and Deb Lowther, for being here today.
I'm going to quote something from another individual who was testifying. Mr. Robert Tomljenovic, area director, Department of Veterans Affairs, was explaining, similar to what you're saying, that veterans, “like the general population, become homeless as a result of complex and interrelated issues such as health status, personal problems, employment instability, poverty, lack of affordable housing, addiction issues and others.” In addition, they have also experienced traumatic scenarios.
I can't help but think that homelessness and all of these things that are mentioned are symptoms of a traumatic experience. Whether you're a veteran or not, something has caused you to go down these paths that make life less positive.
Ms. Lowther, your program, Boots on the Ground, says to me that the majority of people with these traumatic experiences in our armed forces are the people who are the boots on the ground, the ones who face the fire, the explosions and all these kinds of issues. I'm so thankful for what you guys do, all of you, in what is really a crisis management scenario. I'm sure you would love to see circumstances change so that there is no homelessness. That's the ideal. I understand that it's not possible, but we could get much closer to it than we are.
Mr. McInnis, I believe you mentioned something around the issue of their needing to be fit to be transitioned. Our goal here has been to help create this seamless transition from National Defence through VAC to a healthy life as a civilian. Would you say that this area.... I know that VAC is not anxious to allow National Defence to be the ones to determine when you leave—and if you leave with an injury, whether it's service-related or not—in order to not have to go through that whole system again in going through VAC.
You were talking about needing more case managers. Can you talk a bit about that? If those circumstances were different, would those symptoms that our veterans face be different, the ones who are truly injured and struggle with these issues, with PTSD and whatnot?
Thank you very much. Good afternoon, honourable members of Parliament. I appreciate the opportunity to address the House of Commons Standing Committee on Veterans Affairs.
As noted, I'm an associate professor in the department of anaesthesia here at McMaster as well as the associate director in our cannabis research institute.
The cannabis research institute here is funded by philanthropic donation. We receive no industry funding, and our mission is to develop an evidenced-based understanding of cannabis, both in terms of its potential therapeutic benefits and also its associated harms.
Our centre's activities broadly include the synthesis and dissemination of current best evidence, the conduct and support of innovative research in areas where evidence is lacking, and the creation of a research network including both faculty members at McMaster and external partners including Dr. David Pedlar, the scientific director of the Canadian Institute for Military and Veteran Health Research.
My research in particular focuses on evidenced-based medicine, chronic pain, disability management, opioids and cannabis.
We note that military service is associated with health risks. Recent surveys have found 41% of military personnel report the experience of chronic pain and 23% report intermittent pain. Military personnel develop higher rates of psychiatric disorders such as PTSD and anxiety than members of the general public, and they are at greater risk for both suicide attempts and completion.
Regarding the potential role of medicinal cannabis to assist our veterans, we have at present moderate quality evidence that suggests cannabis may reduce chronic pain, but effects are typically modest. Our group here at McMaster is currently revising and updating this evidence synthesis. We anticipate our work will be completed in the first half of 2019.
Regarding the current evidence to support a therapeutic role and management of symptoms associated with anxiety or PTSD, we have anecdotes but we have very little evidence to make conclusions either supporting a benefit or refuting a role.
We have some observational evidence that has shown that, in areas where cannabis becomes available for medicinal use, suicide rates in general seem to track down. We also have observational evidence that veterans who present with cannabis use disorder are at higher risk for suicide attempts. This is another area where more research is needed before we can make firm conclusions.
There are a number of side effects associated with cannabis. These include dizziness, fatigue, euphoria, confusion, disorientation. Cannabis use disorder or addiction occurs in about 7% of regular users over their lifetime, and the adverse events associated with cannabis are predominantly tied to one cannabinoid, THC. The cannabis plant contains more than 100 active cannabinoids, the most studied of which being THC and CBD. CBD may have some therapeutic properties, but it is neither psychoactive nor addictive.
This suggests that cannabis products that contain predominantly CBD may be associated with much fewer adverse events than the plant as a whole. Despite the limited evidence for benefits and the known and suspected harms, the general perception about cannabis seems to be increasingly enthusiastic.
A 2017 survey of more than 16,000 Americans in the general public found that 81% believed cannabis had health benefits; 9% believed it had no risks; 22% believed it was not addictive. These perceptions are not in line with current evidence.
We also know that authorization for medicinal use is increasing in Canada. According to Health Canada's registry of patients, there were about 8,000 who were authorized to use medicinal cannabis in 2014, and at present this figure is closer to a quarter of a million. The rapidly expanding therapeutic use of cannabis suggests a triumph of marketing over evidence. I would suggest there may be some relevant lessons to be learned from Canada's experience with opioids for chronic pain.
At present, over 7,000 veterans in Canada have been authorized to receive medicinal cannabis, and the matter of dosing has been contentious. The precise dosing is not available from current evidence, and a dose of cannabis does not consider the potency, particularly the percentage of THC that may be available in a product. In addition to that, the product of cannabis can be consumed either through inhalation or through ingestion and the way in which you take it in affects both the time of onset and the duration of effects.
VAC currently reimburses up to three grams per day in general for medicinal cannabis and up to 10 grams with approval for exceptional cases. These are not excessively conservative policies relative to other countries. For example, Israel reimburses only one and a half grams per day, the Netherlands 0.68 grams per day. If you look at the data from Health Canada regarding how much cannabis those who are authorized to use it for medicinal purposes are currently accessing, on average it's about 0.75 grams per day. The likelihood of an individual consuming the very high end of what's allowed, 10 grams per day, suggests they are at higher risk for developing dependence and possibly cannabis use disorder. The result of this means that withdrawal symptoms would result if their dose were tapered rapidly or if the product were made unavailable to them, and as such there is a need for both caution and compassion considering veterans who are currently using medicinal cannabis, in particular at higher amounts.
What is needed to promote evidence-based authorization of medicinal cannabis? We need randomized controlled trials to establish effectiveness of cannabis for promising indications. Observational data, which is what we have most of, cannot establish causation, and such trials should enrol adequate numbers of patients to make firm conclusions, follow individuals for a long period of time, six months to a year, and consider capturing both benefits and harms of cannabis use. We require more real-world observational data at the same time. Veterans and other medicinal cannabis users can be enrolled in research cohorts and followed forward in time to look at patterns in change of use, the effect on their symptoms and the development of both long-term and rare events.
We also need guidelines to help veterans, other patients and clinicians make evidence-based decisions around medicinal cannabis. The most applicable area for this would be chronic pain. That's where we currently have the bulk of evidence for the application of medicinal cannabis.
At the same time, evidence alone is not sufficient to make clinical decisions. Because of the likely modest benefits, and the known and suspected adverse events, the decision to pursue a trial of therapeutic cannabis is not straightforward. We require values and preference research so we understand what patients are willing to trade off, given the evidence for potentially modest benefits and the development decision aids would help facilitate shared care decision-making.
On a positive note, with the dedication of appropriate resources, given the current legalization of cannabis and the interest in research, Canada has the opportunity to become an international leader in medicinal cannabis research for both veterans and in general.
In closing, I thank you for the opportunity to serve as a witness for this committee.
Good afternoon, bonjour
, honourable members of the committee and my esteemed colleagues. I would like to express my sincerest gratitude for the honour to be here today.
My name is Dr. Yanbo Zhang. I am a clinician scientist from the department of psychiatry in the college of medicine at the University of Saskatchewan. As a psychiatrist, I treat patients with mental health conditions like depression, anxiety and PTSD. As a researcher, I use animal models to study the therapeutic effects and underlying mechanisms of cannabis as well as other normal treatments for psychiatric and neurological disorders such as depression, PTSD, multiple sclerosis and also traumatic brain injury.
I want to declare my funding sources and potential conflicts of interest. I received research grants from the University of Saskatchewan and also the Saskatchewan Health Research Foundation. I have an ongoing supply agreement from a cannabis company for my animal research, but the company does not influence my experiment design or the outcome of the research. I do not have any financial support or grants received from any industry.
I'm also the secretary-treasurer and the board executive for the Canadian Psychiatric Association. It’s a national professional organization for Canada's psychiatrists and trainees, but here all my opinions are my own, and I do not really represent any of our association’s opinions.
Military veterans have at least a twofold risk of developing PTSD when compared to the general Canadian population. Individuals with PTSD relive trauma through flashbacks and nightmares, and they suffer from extreme fear, irritability, hyper-arousal and negative emotions. Untreated PTSD causes severe and chronic impairment in their cognition, physical health and social functioning.
Psychotherapies are considered the primary interventions for PTSD. Trauma-focused cognitive behavioural therapy, called CBT, is by far the best supported method. CBT aims to change patients’ dysfunctional post-traumatic memories and beliefs and then to reduce or to decrease their response and avoidance towards the traumatic memory. However, due to the stigma, the service access, the cost and the time consumption, few patients engage in psychotherapy. Most patients with PTSD also receive medications like antidepressants, antipsychotics and mood stabilizers, but seldom stay on the medications due to side effects or lack of observed benefit.
Overall, the treatment of PTSD and the outcome are not promising. Studies also suggest that combat-related PTSD is more refractory to current treatments, which is probably due to high a comorbidity of brain injuries, chronic pain, addiction and also some other comorbidities. Medical cannabis has been allowed for PTSD treatment in a few countries, such as, Israel, Holland and Canada.
Although increasing preclinical studies suggest a critical role of the endocannabinoid system in PTSD and the potential of cannabis in treating PTSD, the clinical evidence remains inconsistent. Most trials have limitations, such as, a small sample size or the use of some healthy participants to elicit the anxiety symptoms rather than a real-world PTSD patient. They also use a synthesized cannabis product rather than the whole plant. In addition, the therapeutic dose range and the ratio of different compounds and their effects is unknown.
The systematic reviews, which are the strongest evidence that we normally use to guide treatment, cannot come with the conclusion of any definite therapeutic effects or benefits in terms of cannabis treatment for PTSD.
With little information, the physicians, pharmacists and patients cannot make an informed decision because there's no high quality of randomized and controlled trials on the whole planet of cannabis, which is the major product that has been distributed. It's really difficult for us to make a decision to see whether it should be used or not and what the benefit would be.
Also, there's consistent evidence showing that the heavy and regular use of cannabis with a high THC content is associated with increased risks of cognitive impairment, psychosis and cannabis use disorder, especially in adolescents and young adults, and also in individuals with pre-existing mental health conditions. Given the high comorbidity of depression, traumatic brain injury and substance abuse in veterans with PTSD, the potential benefit of cannabis may be shadowed by the increased risks of cognitive impairment and addiction.
As psychiatrists we are trained to practise evidence-based medicine, which requires us to examine the scientific evidence and to balance the risks and benefits before providing treatment. Thus, many psychiatrists, including myself, are really hesitant to authorize cannabis for treating any psychiatric disorders because we do not know the long-term outcome and we do not know whether the benefit will trump the risk.
On the other hand, effectively treating PTSD is quite a challenging thing. We have to explore new interventions that can benefit our patients. That's why it is critical to understand the therapeutic and adverse effects of cannabis products with different doses and with different ratios of THC and CBD. Research to compare the efficacy of cannabis use and also the currently available treatment, like antidepressants and psychotherapies, are highly needed, so we can find a benefits versus risks profile. Also, we need to determine the long-term effects of cannabis use on the patient's mental, physical and social functions, which is largely lacking at this stage.
The third part is we know that there's a high comorbidity of chronic pain and brain injury and substance use in patients with PTSD. They have a really complicated bidirectional relationship. Adding more studies on the interactions will help us to understand the prevention and the treatment options for the future.
Before obtaining further evidence, the low-risk cannabis use recommendations made by medical professionals should be applied, such as using a high CBD content oil versus using or smoking products with a high content of THC. I believe that the safe integration of medical cannabis can potentially improve the quality of care for the patient, but the robust, large-scale and blind and unbiased studies are needed to achieve this.
Good afternoon, honourable members of the committee. There are no words to say how grateful I am to receive this experience to speak before you today.
I would like to talk to you about my experiences as a soldier, tell you about the obstacles we face as veterans when we seek treatment, and discuss the research I am doing with Dr. Zhang.
I would also like to say a big thank you to Dr. Robert Laprairie, who is a cannabis pharmacologist at the college of pharmacy who helped us review this, as well as Madam Kelly Malka from Montreal, who helped me a little with the translation to make sure it was correct.
I did a 1,000-hour primary care paramedic course at John Abbott College in Montreal. Then at age 19, I left to voluntarily join the military. I served with a light infantry regiment in a combat role as a combat medic, and then in 2013 the contract ended. It was up or out; I chose out and was honourably discharged.
I can say that I'm intimately familiar with PTSD, because unfortunately, I have different friends across the military, as well as EMS circles, who were affected in different ways. I know a paramedic instructor and a friend from the military who chose the permanent end to the temporary problem, which was suicide.
I can also say that the transition period is extremely difficult to live through. Many studies have shown that this period may be the most volatile and where there can be very prevalent use of substances.
In my case, I went from being mostly respected and appreciated as the company and platoon combat medic, to having extreme difficulties with licensing bodies to get back to work in a timely manner. Unfortunately, it's really common to hear about cases like this. That, combined with the fact that you're free to consume drugs and alcohol outside of the military or paramilitary organization that you belong to, is often the deadly concoction that leads to unemployment, homelessness, suicides and other devastating outcomes.
In the military, there's a very strong prevalent culture of substance abuse. Soldiers across the ranks often use alcohol as a tool to self-medicate, and even sometimes to let loose after a stressful deployment or stressful longer period. It's also not uncommon to see especially junior platoons be completely hungover for a 05:00 training session.
Also, many soldiers consume dangerous amounts of things like energy drinks and painkillers like acetaminophen and ibuprofen. They're often combined with cigarettes, chewing tobacco and energy drinks.
In my time, there was also a bit of use of synthetic cannabis. The product was called “spice”, which is a very high-content THC product that has negative effects. It couldn't be detected in urinalysis at that time. I think it can now, but I'm not sure.
Having said that, veterans are often their own worst enemy. There's a reluctance to seek treatment, and there's also some difficulty after service in connecting with others for different reasons. The desire for effects to happen right now hinders progress.
Many veterans who suffer from acute episodes of PTSD are often prescribed very powerful drugs like haloperidol and quetiapine, which are usually reserved for cases of severe psychiatric patients. This is an issue, since PTSD is very hard to diagnose, especially in the early stages, and is often comorbid with other conditions like anxiety, insomnia, chronic pain, hearing loss, tinnitus and others.
The stigma of being soft for seeking treatment, along with being given by physicians what many veterans refer to as the “zombie cocktail”, and being stubborn about treatment, can create a never-ending vicious cycle of distress between patient and clinician.
The fact that PTSD is also comorbid itself with different types of addiction is often a valid reason for physicians to be reluctant to prescribe drugs outside of the recommended guidelines, such as cannabis.
It was at that stage in my life I found that many people, especially veterans, talk but don't proactively take it upon themselves to change the solution. I saw also in friends that the symptoms were from very benign to very severe. For example, one just decided that he was going to defer medical school for a year and take some time off to calm down. At the other end of the spectrum, there were a few who needed intensive treatments, medications, and even hospitalization, for insomnia and nightmares in the early stages of PTSD.
I heard anecdotal evidence that there was some relief from these issues with medical cannabis. It was right when I got out. That's when the story of cannabidiol oil for the aggressive seizure condition, Dravet syndrome, really caught my attention.
I also came in contact with a man by the name of Boone Cutler. He was an American army soldier. A direct mortar impact caused a TBI and he found himself addicted to the very medications that the physicians at Walter Reed prescribed him. He switched to high-content CBD cannabis with THC as needed and has since become a radio host, author, columnist, video director and advocate in general. He made the Spartan pledge, which encourages veterans never to take their own life and “to find a mission to help my warfighter family”.
This led me to follow the military model to lead from the front and take it upon myself to study this. I took eight months after honourable discharge before going back. Even now in school student veterans are hardly seen and we're definitely under-represented just because there are hardly any veterans, period, or clubs on campus. It's also really hard to reach out.
Education on the subject is highly lacking. Even in the pharmacology program where I am now, there are still a few professors who are unaware that new technology has allowed for different compounds of the plant to be isolated and delivered in oil form within an accuracy of 0.01 milligrams per millilitre and as much as 0.25 milligrams per millilitre, depending on the company. Many are also unaware that companies registered with Health Canada as licensed producers usually have really strict guidelines to adhere to. The reputable ones, for example MedReleaf, Aurora, Canopy—I'm not endorsing them; I'm just saying—hold not only GMP but also ISO certification, which is a more strict form of regulation. They have many forms other than dried leaves, such as oils, edibles, vaping solutions and creams.
The issue, though, as both doctors have said, is that many studies and opinions contradict each other. There's not only a chasm between countries, but even within a province. For example, the CMA currently does not seem to support cannabis for PTSD. However, the Israeli Ministry of Health supports medical cannabis after traditional pharmacological options fail or if there's not enough help from psychotherapy within two months. In Israel they also recommend low doses of THC for severe PTSD.
Although patients can be authorized medical cannabis and seem to have reasonable insurance coverage, it's often very bureaucratic and confusing to begin the process since there are so many different requirements within each province, as well as at the federal level.
I believe we need more research into cannabis-based medicines so we can demonstrate their efficacy, if any, in individuals with PTSD. There is also a serious need to better educate health professionals as well as professors teaching these subjects so we can distinguish appropriate compounds from recreational and harmful use.
The current guidelines allow for three grams daily. When we think that this is enough to deliver half a gram of cannabis six times in an 18-hour period, it may seem like a lot but many patients, especially patients who have been to combat zones, may have more severe conditions and may require larger amounts, especially if they have a tolerance or if they're using smoked cannabis, since with smoked cannabis, the maximum bioavailability quoted in the literature that I could find was 56%.
At the moment powerful opioid drugs are prescribed to patients with chronic pain roughly every four hours according to the pain guidelines. Given that they're extremely dangerous and that it's also the driving force behind the current fentanyl epidemic in North America, to me it seems logical to allow for possibly higher doses in severe conditions, especially if they're using smoked cannabis.
Pharmacological information regarding dose responses by body weight, route of administration, and also the type of compounds is completely lacking, even non-existent. Studies in human patients are going to be needed to allow the full elucidation of cannabinoid pharmacology. The lack of treatment options without serious side effects and knowing that cannabis products were being used prior to legalization in both Canada and the United States led to my interest in studying cannabis as a potential therapeutic agent for PTSD.
Although it's a controversial topic, there is some anecdotal evidence of veterans using cannabis to alleviate the symptoms caused by mefloquine toxicity. I needed to determine and I hope to show that even if there are safety risks with cannabis, the benefits outweigh those risks.
During my undergrad I optimized an animal model of PTSD to mirror human exposures and conditions. Animals are subjected to daytime and nighttime exposure and then they get daily cage changes to simulate either a combat deployment, or an EMS shift with different personnel. Using this model, we have found that a low dose, five milligrams per kilogram, of CBD oil can really decrease the PTSD symptoms, and does not seem to have any addictive properties. Although the results are promising, it's still really early and we can't responsibly make any conclusions with respect to humans at this time. We do hope to explore different compounds, doses and ratios in both male and female rats before doing larger randomized clinical trials, hopefully with the Legion.
This is going to be the basis, and it's also the goal for my M.Sc. thesis. We think that more knowledge of the intricacies and mechanisms of our body's endocannabinoid systems will allow us to properly define optimal dosing for each strain and compound of the cannabis plant. Human studies into safety for pediatric conditions, such as Dravet syndrome epilepsy, as well as safety thresholds for cognitive effects when using THC are needed to make better decisions. We think these would benefit clinicians and patients alike.