the costs and benefits of cannabis: social, …...the benefits, risks and costs of cannabis for...
TRANSCRIPT
The Costs and Benefits of
Cannabis:
Social, Medical, and Public
Health Considerations
CADTH Symposium
Concurrent Session D3
May 16, 2019
Edmonton, AB
Welcome!
CADTH Housekeeping
Presentations will be made available on the CADTH web site the
day after the session.
An evaluation survey will be sent out after the symposium and
feedback on this session and the whole event will be greatly
appreciated.
Everyone who fills in a survey is helping raise money for the Pilgrims
Hospice Society in Edmonton, under the HTA Gives Back initiative.
Networking break will take place in the Exhibit and Poster area
(Pedway Level, Hall D and Hall D Foyer).
Setting the Stage
Various medical cannabis access schemes (ACMPR) – since
2001
Cannabis Act 2018
Important to start talking about what it will take to allow
us to integrate cannabis into our health systems, as a tool
in managing a range of conditions
Objective
To present a summary of the evolving evidence
for cannabis in managing key public health
challenges, particularly as it relates to cannabis
as a substitute for prescription and illicit opioids
and other prescription medicines.
Speaker Introductions
Dr. Mark Ware - Canopy Growth Corporation
Dr. M-J Milloy - British Columbia Centre on Substance Use, UBC
Dr. Brian Emerson - BC Ministry of Health
Dr. Judith Glennie - Moderator
Medical Cannabis in Canada Dr. Mark A. Ware
Chief Medical Officer, Canopy Growth Corporation
Associate Professor of Medicine, McGill University
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Disclosure
I have the following relevant financial relationships to disclose:
• Employed by Canopy Growth Corporation (salary and stock options)
I have the following relevant non-financial relationships to disclose:
• Advised Canadian government on cannabis legalization and regulation 2000-2016
• Executive Director of non-profit Canadian Consortium for the Investigation of Cannabinoids (2007-2018)
• Background on cannabis
– medical/recreational cannabis
– cannabis law
– emerging evidence
– current and future research (including RCTs)
• Implications of cannabis legalization for patient care
Objectives
Dr Mark A. Ware McGill University 2017
© Canadian Consortium for the Investigation of Cannabinoids
Oh, Canada…
• Cannabis production
• 145 licensed producers
• 18,000 MDs
• >350,000 patients
• Increasing 10% per month
• Cannabis consumption
• Average amount authorized = 2.1g/day
• Average amount purchased = 0.75g/day
0
2000
4000
6000
8000
10000
12000
14000
Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018
Cannabis sales to patients 2016-18 (kgs)
Flower Oil
Dr Mark A. Ware McGill University 2017
• There is reasonable evidence that cannabinoids improve nausea and vomiting after chemotherapy. They might improve spasticity (primarily in multiple sclerosis).
• There is some uncertainty about whether cannabinoids improve pain, but if they do, it is neuropathic pain and the benefit is likely small.
• Adverse effects are very common, meaning that benefits would need to be considerable to warrant trials of therapy
• Low methodological quality studies • Small trials (n<50); usually positive • Short trials limit long term efficacy assessment • Heterogeneity of “chronic pain” • “Lumping” together all cannabinoids/cannabis based medicines • Publication bias (unpublished negative trials) • Safety assessments poor
• Case reports (e.g. edible overdose)
• Case series (e.g. cannabinoid-induced hyperemesis)
• Clinical trials (phase I-III)
• Post marketing surveillance (phase IV)
• “Real world” observational studies (e.g. COMPASS)
• Epidemiological studies (psychosis, driving, depression)
Cannabis safety
-5.6%
-8.5%
-23.0% -24.8%
-30%
-25%
-20%
-15%
-10%
-5%
0%
Opioid prescriptions(Medicare)
Opioid doses (Medicaid)
Opioid-relatedhospitalizations
Opioid overdosemortality1 4 3 2
States with medical cannabis laws have reductions in:
1. Bradford AC et al. JAMA Intern Med 2018;178(5):667-72;
2. Wen H, Hockenberry JM. JAMA Intern Med 2018;178(5):673-79;
3. Shi Y. Drug Alcohol Depend 2017;173:144-50;
4. Bachhuber MA et al. JAMA Intern Med 2014;174(10):1668-73.
M-J Milloy, PhD Research scientist, British Columbia Centre on Substance Use
Canopy Growth Professor of Cannabis Science,
Assistant Professor, Department of Medicine, UBC
CANNABIS FOR HARM REDUCTION:
INVESTIGATING THE USE OF CANNABIS TO
ADDRESS THE NATIONAL OPIOID CRISIS
DISCLOSURE
• I have no conflicts of interest to declare
• I have no personal financial relationships to the cannabis industry
• I am supported by:
– United States National Institutes of Health (U01-DA0251525);
– New Investigator award from the Canadian Institutes of Health Research;
– Scholar Award from the Michael Smith Foundation for Health Research;
• The University of British Columbia (UBC) has received an unstructured gift from
NG Biomed, Ltd., to support me;
• The Canopy Growth Professorship in Cannabis Science was established through
arms’ length gifts to UBC from Canopy Growth and the Government of British
Columbia’s Ministry of Mental Heath and Addictions
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I respectfully acknowledge the land on which I live and
work is the unceded traditional territory of the Coast
Salish Peoples, including the traditional territories of
xʷməθkwəy̓əm (Musqueam), Sḵwx̱wú7mesh
(Squamish), and Səl̓ílwətaɬ (Tsleil-Waututh) Nations.
25
Source: Government of Canada,
www.canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids/
OPIOID OVERDOSE CRISIS
• Unprecedented numbers of opioid-related deaths across
United States and Canada
• Contributing factors include:
– Over-prescription of opioid analgesics;
– Contamination of illicit opioid supply with fentanyl;
– Public security-based approaches to illicit drug use
26
OPIOID OVERDOSE CRISIS
• Low coverage of evidence-based approaches to opioid
use disorder & OD
– Opioid agonist therapies (e.g., methadone,
naloxone/buprenorphine, injectable diacetylmorphine)
– Peer-delivered naloxone
– Supervised consumption facilities
• Urgent need for new approaches to lower risk of
overdose
27
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Table 1. Association between medical cannabis laws and state-level opioid
analgesic mortality rates in the United States, 1990–2010
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• Ecological evidence from United States suggests a
beneficial link between cannabis and opioid overdose
• Need for individual-level analyses on relationship
between cannabis use and overdose risk
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BCCSU Cohort Studies
– Three harmonized and complementary prospective cohort studies of > 3,500 people who use drugs (PWUD) in Vancouver
• Vancouver Injection Drug User Study (VIDUS): 1,500 HIV- people who
inject drugs (1996-);
• At-Risk Youth Study (ARYS): 1,000 street-involved youth who use drugs (2005-);
• AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS): 1,100 HIV+ PWUD (2005-)
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BCCSU Cohort Studies
– Individuals recruited from community settings in Downtown Eastside and Downtown South
– Biannual interviewer-administered questionnaire and nurse-led examination (HIV [ab, CD4, VL, geno], HCV [ab], UDS)
– Elicit data on sociodemographics, drug use, health care access, risk behaviours, etc.
– > 3,500 individuals & > 20,000 longitudinal interviews (1996–)
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RESULTS
• Cannabis use prevalent among people at risk of OD
– 56% used at least once in last six months;
– Among people who used cannabis in last six months, 40%
smoked cannabis at least daily
33
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Intention Any use L6M Most important use
L6M
To relieve pain 32% 17%
To help with sleep 34% 10%
To help with HIV medications/AIDS symptoms 2% 1%
To treat nausea/lack of appetite 24% 8%
To substitute for other substances 12% 4%
To relieve stress 37% 16%
To treat a mental health concern (other than addiction) 15% 7%
To get high or socialize 45% 34%
Table 1: Self-reported reasons for recent cannabis use among 1425
people who use illicit drugs in Vancouver, Canada
35
Among 810 individuals initiating opioid
agonist therapy, ≥ daily cannabis use was
associated with a 21% greater likelihood
of being retained in treatment six months
later during 9,284 person-years of
observation (Adjusted Odds Ratio = 1.21,
95% CI: 1.04–1.41)
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37
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Among 669 people who use illicit drugs during a
community-wide overdose crisis, having a positive
urine drug screen for fentanyl was negatively
associated with a positive urine drug screen for
THC (AOR = 0.52, 95% CI: 0.31–0.83)
WORKS IN PROGRESS
• Among 2,619 active people who inject drugs, frequent cannabis use was significantly and longitudinally associated with decreased frequency of injection drug use (AOR = 0.81, 95% CI: 0.73–0.89)
• Among 1,160 people who use illicit drugs with chronic pain, frequent cannabis use was significantly and longitudinally associated with lower odds of daily illicit opioid use (AOR = 0.46, 95% CI: 0.31–0.69)
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LIMITATIONS
• BCCSU cohorts not randomly recruited;
representativeness to other groups of people who use
drugs unknown;
• Some drug use data self-reported;
• Time of detection for urine drug screens differ by
metabolite;
• Retrospective data on cannabis use does not include
details of cannabis type, route of administration, dose,
etc.
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DISCUSSION
• Cannabis use common among people at risk of opioid
overdose
• >75% report therapeutic use of cannabis (pain, nausea,
sleep, substitution)
• Cannabis use associated with:
– 34% lower odds of non-fatal overdose;
– 21% greater odds of retention in treatment of opioid use
disorder;
– 48% lower odds of exposure to fentanyl
42
CANNABIS TO MITIGATE OPIOID CRISIS
Findings support need for experimental trials among
humans
– Are cannabinoid-based interventions effective at reducing risk
of drug-related harms during a community-wide overdose
crisis?
M-J Milloy, PhD
Research scientist, BC Centre on Substance Use;
Canopy Growth Professor of Cannabis Science,
Assistant Professor, Department of Medicine, UBC
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Best Brains Exchange: The Benefits, Risks and Costs of Cannabis
for Therapeutic Purposes
2019 CADTH Symposium, Edmonton
Dr. Brian Emerson, A/Deputy Provincial Health Officer
BC Ministry of Health
April 16th, 2019
Disclosure
I have no financial relationships with cannabis or
pharmaceutical commercial interests
Employee Vancouver Island Health Authority/BC
Ministry of Health
No actual or potential conflicts of interest
47
Best Brains Exchange
June 15, 2018 in Victoria, BC at
the Ministry of Health
Collaborators:
Canadian Institutes of Health
Research
Michael Smith Foundation for
Health Research
BC Centre on Substance Use
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Objectives
Bring together stakeholders to explore what information and
research is needed to develop policies for the therapeutic use of
cannabis in BC
evidence and gaps on benefits, risks, costs and professional training
requirements;
how other jurisdictions have addressed;
ways of acquiring/generating evidence to assist in determining whether
cannabis should be covered as a publicly insured benefit.
49
Key Themes
Pan-Canadian research strategy needed
Legalization makes cannabis research timely
Need for coordination and consistency of approach in cannabis
research
Canada has opportunity to lead in open science
Important to bring multiple stakeholders to the table
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Key Themes cont’d
Opportunity to study the intersection between cannabis, pain and
opioids
Respect for Indigenous people and Canada’s many cultures
Cannabis “not a good fit” for current clinical trial and regulatory
pathway used for pharmaceuticals
Opportunity to look at current insurance coverage for medical
cannabis to research cannabis use and coverage in parallel
51
What Evidence is Needed?
Data on cost-effectiveness, including comparisons to other drugs
and impact on quality of life;
Clinical trials looking at prime areas of current use, including pain
control, nausea, spasticity and sleep assistance; and,
Attention to the current barriers, including the difficulties in the
regulation of medical cannabis.
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How can Evidence be Gathered Efficiently?
Focus on issues where there is already evidence for the efficacy of
cannabis (e.g., pain control to alleviate use of opioids);
Clinical trials; and,
Bring multiple stakeholders together to put studies and funding
together (including regulators, medical associations, societies that
represent patient needs, licensed providers, and government
research funders).
53
Capitalize on Natural Experiments
Look at use and outcomes data
Learn from the current practices of insurance companies
Learn from patient advocacy work that has already been done
Create academic partnerships to include data sharing
Link medical cannabis use to administrative data
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Next Steps & Recent Developments
BC Research Network established
CIHR Integrated Cannabis Research Strategy
Research registries to promote coordination (CCSA, CCIC)
Question on insurance coverage for medical cannabis to be included
in Canadian Cannabis Survey (data collection in spring 2019)
55
Next Steps & Recent Developments Interim report from the Advisory Council on the Implementation of National
Pharmacare (Eric Hoskins, Chair)
Recommends developing a national formulary – should cannabis be included?
Towards open science: Promoting innovation in pharmaceutical research and
development and access to affordable medications both in Canada and abroad
(Standing Committee on Health)
Canadian Pain Task Force - provide advice to Health Canada regarding prevention
and management of chronic pain.
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Audience Q&A Please state your name and organization prior to sharing your question.
CADTH Housekeeping
Presentations will be made available on the CADTH web site the
day after the session.
An evaluation survey will be sent out after the symposium and
feedback on this session and the whole event will be greatly
appreciated.
Everyone who fills in a survey is helping raise money for the Pilgrims
Hospice Society in Edmonton, under the HTA Gives Back initiative.
Networking break will take place in the Exhibit and Poster area
(Pedway Level, Hall D and Hall D Foyer).
Thank you!