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E69 - Can cannabis reduce pharmaceutical costs?

Philippe Lucas from Tilray comes on the discuss the TOPS (Tilray Observational Patient Study).  It looked at around 2000 medical cannabis patients across Canada prospectively and gather tons of data.  Some of the most interesting findings include medicating with cannabis seems to reduce opioid use and the use of prescription medications in general.  Plus, there was no signal that the study participants wanted more and more cannabis which implies limited drug seeking and addition behaviors from medical cannabis.  Numbers, data, cannabis, a great chat with Philippe, are you as excited as Trevor about this one?  Have a listen.

Sunday, 23 May 2021 10:58

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Episode Transcript

Trevor: Kirk, we're back,. 

Kirk: We're back. How's it going? 

Trevor: Good.

Kirk: So this is the second. This is the second episode of a series of cannabis assisting with opiates. 

Trevor: Yes. Yes. And this one, another cool one that kind of fell in our lap. So that's well, we'll do some of the officials off the top. So, it's got a really long actual title. "Cannabis Significantly Reduces the Use of Prescription Opioids and Improves the Quality of Life in Authorized Patient Results of a Large Prospective Study." Thankfully, there must have been some marketing people around and that has been shortened to TOPS. 

Kirk: TOPS is

Trevor: TOPS the Tilray Observational Patient Study? 

Kirk: OK. 

Trevor: So, we've got one of the lead authors, Philippe Lucas from Tilray. This was a really big study, so one thousand one hundred forty-five (1145) patients in 21 cannabis clinics across Canada and they were followed up at one, three and six months. So, yeah, this is this is a big group of people that were started on cannabis and then they asked them a bazillion questions at baseline at one, three and six months and to see how medicinal cannabis affected them, especially how it affected their opioid use. But other stuff, too. So this just kind of scream Reefer Medness all over it. So called; sent a message to, cause we could do that now, just send a message to you-know the vice president of Tilray, a soon to be Dr. Philipee. 

Kirk: PhD candidate. 

Trevor: PhD candidate, defending in March. So if you're listening to this after March twenty twenty one (2021), hopefully a a a properly defended and dissertate PhD dude. But yeah, a really interesting to talk to.

Kirk: I've looked him up and he's he's he was a Victoria town councilor in my hometown, Victoria, City Councilor and regional director. In 2008 to 2011. He wrote a paper, I don't know if you know this. He wrote a paper in two thousand and twelve about cannabis as an adjunct to or substitute to opiates. So, he's been he's been looking at this for a long time. I wonder if this this paper is the precursor to his PhD study? 

Trevor: Well, and that's what it sounds like. Like he refers to it a couple times. And because he's a VP, I only had him for like half an hour or so to try not to go down too many rabbit holes. But, yeah, he said he's been sort of off and on in the cannabis research thing for 20 years, and he's done some masters work. He's did some, like you said, actually started, I hope I'm not getting this wrong, but I don't think it was the Victoria Cannabis Buyers Club, which you went to, but another similar entity. Yeah, he's been he's been in the cannabis world for medicinal cannabis world for 20 years. 

Kirk: Yeah. He is the founder. He was the founder of Vancouver Island Compassion Society in nineteen ninety-nine. 

Trevor: There you go. That's the one. Yeah. No, no, he's just a very knowledgeable guy. Knows, knows cannabis from the from the patient side, from the what you want to call it the promoter --that's not quite the right word -- advocate's side. And now into the corporate side and the academia side. So I'm not going to find a much more well-rounded interview than Philppe. 

Kirk: Yeah, no, it's a good interview. I am again researching here and researching his study. One of the offshoots of his study also discovered that cannabis as harm reduction; studies show that patients that use cannabis also drink less alcohol. Yeah. So, I mean, it's fascinating what cannabis, you know, as we sit and learn and this is what you and I are doing with this project, Reefer Medness - The Podcast, I'm the nurse Kirk Nyquist 

Trevor: and I am Trevor Shewfelt, I'm the pharmacists. Look, we said it before the interview this time. 

Kirk: Yeah. Yeah. So what are the things we try to do is we're trying to learn about cannabis and once again, canna-positive, this is a PhD candidate and fellow that's been studying cannabis for 20 years. He's credentialing himself, as a PhD an expert of cannabis. And cannabis has a role to play with the opiate crisis at North Western societies, 

Trevor: North America for sure. But yeah, probably farther than that. 

Kirk: Oh, oh, gosh, man. European countries, it's the opiate opioid. I mean, it's killing people along with the pandemic. So again, cannabis pounding, pounding my wooden counter; cannabis has a role to play. This guy's done a study and again I get excited, I get excited when we have these studies. I mean I know there's lots of lived experience in this program. We talked a lot of the lived experience. But when people come out and a large study and I mean, you must be thrilled. Oh yes. A large study. Right. It's like a large study has come out and said, look, cannabis can actually be first line. 

Trevor: Yeah, no. And just this is a number lover's dream because they collected so much data on these guys and we only really touch on the opioid part. But, you know, they looked at benzodiazepines, which went down; like SSRI, which are like anti-depressants went down. Yeah, yeah. Just so many things. When people use cannabis now, it is only six months and there's always holes you can poke in these things. But, you know, one of it's sort of headline numbers is so we'll get a little nerdy here. So, we talk about morphine milligram equivalent. So that's like one milligram of codeine is not the same as one milligram of morphine, which is not the same as one milligram hydromorphone. So you can compare them sort of apples to apples that they have us do a little bit of math. So, you can say this much codeine equals this much morphine and it's called morphine milligram equivalents. Don't worry about all the math, but basically if you take the amount of opioids people use, so they measured in morphine, milligram equivalents of one hundred and fifty two milligram morphine milligram equivalents. At the beginning they went down to thirty-two point two at the end. Like that is a huge drop in the amount of opioids that these people were using over the course of the study. So it's that's that's a headline in of itself. But like I said, they looked at so many other things. They I feel a little sorry for the study participants. They must have been at each visit must have been an hour long just to collect all the info they're looking for. 

Kirk: But, you know, when we want to put this into clinical practice and neither one of us are prescribers, right? We live we live with the with the prescriptions that are given to us and how we educate our clients with them. But I think one of the things I really liked about this study is I think it's got to remind family physicians that 75 to 80 percent of those people ended up overdosing on cannabinoids, on opioids. 

Trevor: with a prescription that came from my pharmacy or a pharmacy. 

Kirk: Yeah. Yes. Right. So, we as we as white coat pushers, white coat prescription, you know, medical professionals that are offering people these deadly medications, I think it's incumbent to us to remind prescribers that maybe if they are thinking about using opiates for somebody with acute pain, that they also consider entering them into the medicinal cannabis stream as well. And I think I think that is something that I pulled out of this, that this study is that cannabis should now start being a primary frontline medication for acute pain. 

Trevor: Yeah, I agree. You know, neither of us get to write clinical practice guidelines, but if when the Pain Society gets around to it, I'd like to be bumped up from third or fourth line to first or second line. And Philippe talked about this a little bit. Now, remember, both him and I are biased, so we'll just clarify upfront. He works for a company that sells medicinal cannabis. I work in a pharmacy, but it would make a lot of sense if medicinal cannabis went through pharmacies. And it would make a lot of sense if the if it was covered by by drug plans and provincial funding bodies like in Manitoba, it's called pharmacare because and they even pulled because they collected to get so much data. They even pulled some numbers out to sort of say, hey, if you insurers paid for medicinal cannabis, the way you pay for every all other medications, it might actually save you some money because of all these medications that would go down or away. So, you know, again, this is going to be an ongoing thing. And yes, I come from a pharmacy. And yes, if this went through, I would make money on it. So we'll throw that out up front. 

Kirk: But well, hold on. You might actually lose money, because if you guys were allowed to dispense capsules of THC along with a bottle of Tylenol 3s, where would you be making your money if you're selling less narcotics and benzo? 

Trevor: But do you really? Yes, in theory that's possible. But do you really think there are less people who are going to come through the doors with chronic pain, trouble sleeping, migraines, etc.? So so, you know, it might be. It might be, but less medications to patient X, but I think there will be a whole bunch more to know. Not worried about that at all. 

Kirk: This study tells me that we can we can go that route, that that's where we should be going. Instead of saying, here's your script for Tylenol 3s, get out of here and maybe I'll give you a second or third, because, you know, because pain doesn't always go away. Sometimes you live with pain. You're getting out of bed at 60 years old. This is a reminder that my knees are 60 years old. But I don't know, Trevor. I think I think what this study does for me, it reminds me that I we have an argument when we talk to doctors, it say anybody that that pushes cannabis is just as just the pusher and making money off street drugs now legal. I think I think this tells us that family docs can actually help with the opiate crisis by giving prescriptions of THC, CBDs with their with their acute meds. 

Trevor: So that equates nicely into Philippe. So and a reason you have to come back because somebody is out there is going to say, well, if you're just taking them off of opioids and putting them on cannabis, are we just treating one addiction for another? Phillies answer that let's listen to Philippe and then we'll come back. 

Trevor: Today on the line, we have Philip Lucas' from Tilray, and they have done a really interesting study. But Philippe, before I get it to the TOPS study, could you tell us a little bit about you and your background and how how you got here? 

Philippe: Sure. Thanks for the interest in this work and research. I've been involved in medical cannabis for about twenty-five years now. I started out as a medical cannabis patient in nineteen ninety-five when I was diagnosed with Hepatitis C and I found that cannabis was helpful in addressing some of the symptoms and associated with Hep C: nausea, leak of appetite, localized pain related inflammation around my liver. But I was having trouble finding a safe, consistent supply of medical cannabis. So, in nineteen ninety-nine I opened up the Vancouver Island Compassionate Society, one of Canada's first medical cannabis nonprofit dispensaries, and ran that organization as a nonprofit for about 10 years. And then that's where I started my research and academic career. I went back to university to get a Master's and now I'm just finishing up a Ph.D., all focused on cannabis research. And my research really focuses on patient patterns of use and the use of medical cannabis as a substitute or an adjunct to the use of prescription drugs, particularly opioids, alcohol, tobacco and illicit substances. And I've been until right now for about seven years on the earliest Canadian hire still. And my job there is I hold a number of files, but I also, along with the clinical research team, oversee clinical and observational research program. 

Trevor: Thank you. Back when we were allowed to travel, Kirk actually went out to the Victoria Cannabis Buyers Club and did some interviews there. So, we know the West Coast has a long history of being involved in medical cannabis. And sorry I think I missed it what what's your PhD in? What are you studying? 

Philippe: It's in the Social Dimensions of Health. It's a program at the University of Victoria. And I also formerly had an affiliation with the Canadian Institute of Substance Use Research out of the University of Victoria as well. And I'll be pleased to say I'm going to be defending that PhD in March of this year. So, I'm really just in the final days after seven and a half years work on that. So, it's nice to get this get this done. 

Trevor: Well, congratulations. OK, let's get into the TOPS study. So, this is a big trial. You guys have brought in over two thousand people in initially and then how about, or walk me through what were you hoping to find and how did you set this up? 

Philippe: Well, the goal of this study was really threefold. We are hoping to learn more about how medical cannabis patients across Canada were using medical cannabis. And we gathered a lot of information on patient demographics and cannabis use, patterns of use, preferences for, for example, different methods of ingestion. We also ask patients not just preferences, but what the primary method of ingestion was. Preferences and for THC or CBD products and that kind of thing. But we wanted to look at the intersection between those primary patient characteristics and the use of medical cannabis and then prospectively associated changes in prescription drug use and in quality of life. So, for quality of life, we use the World Health Organization for Quality of Life, short form, one of the most validated Quality of Life instruments out there. And for prescription drug use, this was an in-clinic study that took place in twenty-one clinics. And the physician, or health care staff actually entered down to the milligrams, the prescription drugs that patients were using at baseline when they started the study and then again at one month, three months and six months. So, we were able to gather very granular view of prescription drug use over the six-month period as and the first six months when patients were registered with Tilray to look at the impact specifically of prescription physician supervised medical cannabis use on a number of different conditions. And it turned out to be the largest national prospective study of medical cannabis patients to date. And we're very grateful to the twenty-one hundred patients and the twenty one medical clinics across the country that participated in the study with us. 

Trevor: Yeah, and it just bears repeating. So you had eleven hundred and forty five patients actually complete the trial, which is a huge number and. And so the other thing that I just found interesting, these were people enrolled prior to October 15th, twenty eighteen was that because after that it was going to be available recreationally or just that's just what had happened to be. 

Philippe: That turned out to be the break date for when we decided to do what was initially we would consider that a preliminary data analysis, but it ended up being our ultimate data analysis. And that was a date that from our data pool that would have allowed patients, participants to have the opportunity to be in the study at least six months so that we could see if they had actually dropped out or not. We didn't want to cut off anyone that might be filling in, that might be participating beyond that date. But it ended up being a rather auspicious date, as you as you know, because it ended up, as we all know, being the date of legalization. And in an associated paper, we've now looked at retention in prospect of medical cannabis studies like this and the impact of legalization on retention in studies. And certainly worth noting that legalization did impact retention significantly in this study and that we saw about a three hundred percent increase in patients that were lost to follow up post legalization as patients migrated from the medical system in the recreational system. Of course, it's too early to tell if that's a long-term migration, but certainly Health Canada's data suggest that following legalization, we did see a lot of patients who were moved over into the legal system, into the non-medical system. And so I think that that's an issue for medical cannabis program that need to be tackled over the next few years. I think that there are ways to address this migration. I think that cost covered for medical cannabis would ensure that that patients are incentivized to stay in the authorized medical cannabis program and not just self-medicate through the recreational system. And I think that community-based access through pharmacies would add a level of convenience and a level of health care oversight in the use of medical cannabis that would really benefit patient outcomes as well. 

Trevor: Yeah, well, preaching to the choir on that one, I obviously biased, but I think medical cannabis should go through pharmacies. I know there's arguments on both sides, but I've only got you for a short time. I won't go down that rabbit hole. Let's talk let's talk a little bit about your patients that came in before we talked about what happened. So I've got notes here saying things like they were on average married about 52 more females than not, college educated. So, can you talk a little bit about what you found in the people who were enrolled for the study? 

Philippe: Yeah, well, I was very excited as a cannabis researcher to see that this was there was a slight majority of female participants compared to male participants in the study. As someone who's been involved in cannabis research now for almost 20 years. There was a time when data on medical cannabis was mostly based on men. Men were earlier adopters to medical cannabis use, I think, because of its long-time stigma and illicit nature. And so, when I started doing surveys of cannabis patients, those surveys used to be about seventy five percent male and twenty five percent female. So it was very exciting that in a few of the prospective studies that Tilray is now involved in, that we're seeing either an equal gender balance or even a slight majority of women who are participating in the program. And I think there's good reasons for that Trevor, I think that the increase in the number of women in the federal medical cannabis program is due to well, there's a number of conditions that have a highest prevalence, higher prevalence in women such as fibromyalgia, headaches and migraines, stress, anxiety, depression, lupus, for example, that don't respond very well in a lot of cases to prescription medications, but they do respond very well to medical cannabis. So, I think that's one explanation for why we're seeing more of a gender balance, both in the research that I've been conducting, but also in the federal medical cannabis program as a whole. 

Trevor: So that's great. So let's talk about some of the results, because like you said, since you measured so many things, we got lots of different interesting things out of this. So being a pharmacist, you know, the thing that struck me first is the number of prescriptions the patients were on at baseline was about twenty eight percent of them were on something and then by the end of it, about 11 percent. So that's quite a quite a decline. 

Philippe: That's right. We saw a really significant decline in prescription drugs, and they're specifically the data that you're sharing is specific to opioids. So, we saw that at baseline, 28 percent of study participants were or taking opioids. And within six months, that had dropped to eleven point three percent. So, a really significant decline in the actual percentage of patients that we're using opioids. And along with that, we saw a significant decline also in the average daily dosage of opioids that patients were using. So, the that finding was that initially using what we call the morphine milligram equivalent scale, which you'd be familiar with and with which physicians use often to compare low grade opioids like codeine to high grade opioids like OxyContin, for example. So, using MME mean we found that the average dose at baseline was one hundred and fifty two milligrams of opioids per day, and that at six months that was reduced to thirty-two milligrams a day. That's a 78 percent reduction in the actual daily dose of opioids for those that remain on opioids. So really remarkable findings from opioid harm perspective. 

Trevor: Absolutely. Everybody out there by now has heard about the opioid crisis. Maybe many people don't realize that, you know, people like me and white coats contribute to that because a lot of the opioids people accidentally or less accidentally overdose on actually started at a pharmacy. So, if we can reduce the number of prescription opioids out there, that's good for everybody. 

Philippe: Yeah, I think I think you're exactly right from another publication. I did. If I recall, it's something like 75 or 80 percent of those that end up overdosing on opioids started with a medical prescription for opioids. So, there's a really big link with early non-problematic use associated with, say, a medical condition and then the progression of that use going to non-prescription use. And then then, of course, once you get start buying opioids in our contaminated illicit market, you have a much higher risk at that point of opioid overdose and potentially death. So, I think that if we can decline, if we can reduce our dependence on opioids from a medical perspective, the physicians have more tools in the tool belt to deal with chronic pain, including medical cannabis. You can either stop patients from initially starting down an opioid pathway by prescribing cannabis first, or you can reduce the actual opioids that they're using. So as patients find that they get acclimatized to their opioid dose and they come in to see a physician increase that dose or the type of opioid they're using in terms of potency. Instead of doing that, if you can prescribe cannabis as an adjunct treatment, that might be able to reduce that and prevent that that kind of pathway that could lead to dependence and overdose. And then the other exciting data unrelated to this study, but certainly from similar groups in B.C., the BCCSU is that there seems to be a link between daily cannabis use and adherence to methadone and Suboxone treatment. So opioid therapy. Yeah, and so it seems to be associated with an increased retention. And also, other researchers have found lower withdrawal and cravings. And so, I think that medical cannabis as an adjunct to methadone Suboxone is a very interesting area of research that needs to be it needs to be considered and move forward. If it can increase the rate of success of opioid agonist therapy, you can literally save lives. 

Trevor: And because I can hear someone in the background right now screaming at their phone saying, yeah, but you're just changing one addiction for another. You had another interesting thing in there about the amount of cannabis people were using over the six months. Did it did it go up? Did it go down to stay the same? What did you find? 

Philippe: Yeah, well, thanks for mentioning that. We found something quite remarkable. There's always this concern, understandably, and answer this question all the time by physicians about whether or not patients get habituated to the dose of cannabis that they used and therefore have to develop a tolerance and you have to increase the dose over time. That does happen with opioids and with some other medications. But what we found is that there was no statistically significant difference between the baseline dose of cannabis products the patients were using or the dose that one month when they'd actually been exposed to cannabis for at least a month's time and the six month dose. So. there was a slight increase, but it wasn't statistically significant. So, based at least on our data, within the first six months, there didn't seem to be a tolerance to the therapeutic effects of cannabis. But what we often hear from patients is they develop a tolerance to some of the side effects of cannabis-based medicines via the red eyes, dry mouth and in some cases even the impairment associated with THC. So this was a good news finding for those who were worried that that, as you suggest, or just replacing one drug with another. And just to add one more point to that, you know, we're always a society. I think we've we now understand that that the goal of harm reduction is not always abstinence based. It can be about reducing the harms associated with substance use. And when it comes to medical cannabis, the harms, the harm benefit ratio of medical cannabis compared to opioid, favours medical cannabis significantly, in terms of the overall safety profile, there is zero risk of actual overdose and death, a much lower risk of dependence forming and overall far fewer side effects associated with medical cannabis than opioids. So, if patients can successfully treat chronic pain and other conditions using medical cannabis rather than opioids or even, let's say, benzodiazepines and a non-opioid pain medication, there could be some significant benefits in the harm reduction perspective. 

Trevor: And because I know I'm running short on time, but you actually squeeze nicely into. So, you didn't just look at opioids. You had you looked at non-opiate pain meds, anti-depressants, anti-seizure meds and benzodiazepines and sort of list of things you were looking at. So what happened to the amounts of those that the people were taking? 

Philippe: Well, we used a formula devised by the World Health Organization called Defined Daily Dose that allows you to compare different anti-depressants and different benzodiazepines or anti-seizure medications with different pharmacokinetic effects, but allows a cross comparison of those. And so, looking at the Defined Daily Dose in the five other classes of drugs, primary classes of drugs mentioned by patients other than opioids, which are: non-opioid pain medications, anti-depressants, anti-seizure drugs, benzodiazepines, as well as sleep aids and muscle relaxants, we saw statistically significant reductions in the Defined Daily Dose of all of those drugs as well. And so while we have a very visible public opioid overdose crisis, a lot of Canadians don't realize we also have a very deadly benzodiazepine crisis injected as well. The combination of benzodiazepines that are highly dependent's with alcohol often leads to significant morbidity and mortality. So if you can reduce the dependence on benzodiazepines and some of these other non-opioid pain medications, you get a significant net public health benefit. But I also want to add that we also looked at the medication costs associated with all this prescription drug use. 

Trevor: Good. I want to ask you about that part. Yes. 

Philippe: Good. Good. And we saw that at baseline all this prescription drug use equated to about one hundred and six dollars per month worth of prescription drug spending on average by patients, and that that at six months was reduced to eighteen dollars per month. That's an eighty seven percent reduction in prescription drug use costs overall, excluding the cost of cannabis. And so really significant. And as someone who's been advocating for cost coverage of medical cannabis by private payers, and ultimately, I believe that should be covered by public insurance and or provincial insurance coverage. This goes a long way to making that argument that you reduce prescription drug use cost when patients use medical cannabis. 

Trevor: I love this study and there's so much more, but I know we only have you for a limited time, so maybe I'll just go to this. Was there anything you wished I'd asked or anything else you wish my listeners, our listeners, knew about the TOP study or anything else about sort of what you found about people who use medical cannabis across Canada since this is such a large and detailed survey? 

Philippe: No, I really enjoyed this discussion. And I think the only thing that I mentioned is at the same time as we saw, be significant reductions in opioid and prescription drug use. We also saw statistically significant improvements in all four domains of quality of life. And we saw the greatest changes in physical health where we saw a 30 percent increase in quality of life and in psychological health, where we saw a 17 percent increase in the overall psychological health of these patients. So really exciting. And I think that from that data, if I had to summarize the findings that the Tilray Observational Patient Study is you've got a group of patients who are largely affected by chronic pain and mental health conditions. You introduce medical cannabis in their course of care and then you get an associated reduction in use of prescription drugs, including prescription opioids and statistically significance improvements in quality of life, so really exciting to see this finding and certainly supportive of what patients have been sharing with us for so long, but nice to have the significant data set to point to those outcomes as well. 

Trevor: Oh, yeah. Having numbers to back up what patients and clinicians have been saying for years is fantastic. Philippe this was a great chat. I really enjoyed it. And I know our listeners. I really enjoyed this interview as well. Thank you very much for your time. 

Philippe: Trevor thank you very much for the interest and thanks to your viewers as well. We've got some other really exciting findings just coming out over the next few weeks. So I really hope we have the chance to do this again. Have a great day, Trevor. 

Kirk: So, Trevor. So that's just this is your second episode on the opiates and you said you might have a third coming. 

Trevor: Maybe there are some guidelines, Canadian Guidelines that are coming out now. They're talking about how you could get somebody off of a patient off of or reduce their opioids with cannabinoids. So, I'm chatting with a gentleman about that one. So hopefully that turns into it. But let's talk about Philippe. So, the question I posed just before we went into the interview. So, do you remember what Philippe said about so what happens if we just sort of take somebody off of an opioid and put them out of cannabinoid? Aren't we treating one addiction for another? Do you remember his answer? 

Kirk: I'll let you go for it. 

Trevor: So, he said, of course, they looked at that and a big part of their study is they found, you know what, they put somebody on medicinal cannabis at X level. What you don't want to see is the amount of cannabis they use start of increase and increase over time because, you know, that might be the beginning of an addiction, a problem or whatever. That's not what they saw. It was relatively flat and sometimes even flat slide going down. So, putting somebody on to a cannabinoid didn't seem to be putting them on something that they wanted more and more of. Now, again, it was only six months. And there's going to be. But it's just that, you know, at least over the six months, it wasn't like we started up here and there and the dose just took off. 

Kirk: Right. They didn't they did substitute I mean, one of the one of the problems with opioids is that you get the pain from the drug. So, if you if I'm on opioids chronically and I'm taking it every day, eventually creeping, creeping, creeping, creeping. And with cannabis, the thought is, well, people get tolerance. You know, I smoke so much of it, I'm not getting high. Well, yeah, but they didn't see that. The other thing about cannabis is that once the acute nature of the pain is done and you should be weaning yourself off the Tylenol 3s or whatever to you using, you also can take a break from cannabis. And we learned from Sue when she takes a break from cannabis with her Lyme disease, you know, a week or two weeks break, she comes back and she can use less cannabis and get a response. So, they found I guess they found that way that it doesn't happen. She found it anecdotally. She found taking a break helped to use less cannabis. So, it could be also the individual, but 

Trevor: and obviously more to learn. And their study was only six months long. And but still, it's still just I know I said a bunch of the beginning. Worth repeating. This was big. Like there was lots of people in lots of places.  So, you know, the cannabis studies there just, you know, 20, 20 stoners in Vancouver who, you know, they looked at know across Canada over fourteen hundred patients. This was a big prospective study. So this is this is really good to add to the evidence. 

Kirk: Another thing that I think can happen with this study is governments can look at it because governments right now are also I mean, the Pharmacare and Pharmacare in Manitoba, 

Trevor: in Manitoba, it's called Pharmacare, where the government helps pay for your medication. Yeah. 

Kirk: So people that are on chronic analgesics, are those pills covered in Pharmacare? Yeah. OK, so one thing this study taught us is that people that substitute or use cannabis in conjunction with their opioids is that their costs have gone down. Yes. So governments so governments again, governments could save money by putting cannabis into pharmacies and allowing family doctors and pharmacists to augment its use with pain. 

Trevor: If there was coverage. But yeah. And maybe another episode for another day. But yeah, that is a current issue with patients. And so, you know, let's say I was on two hundred dollars a month worth of morphine, but, you know, was paid for by, by provincial program, even if you would only take me one hundred dollars worth of cannabis a month to have the same effect. You know, from my pockets point of view, I go from paying nothing to paying one hundred dollars a month, so not having not having any sort of coverage on medicinal cannabis I don't think is good for patients. 

Kirk: I don't think so. I mean, I very fortunate. I don't not have any family doctor prescribed medication. So the times that I have come to your pharmacy and I submit my prescription and you tell me there's no fee, and what do you mean there's no fee? That must be the that must be Pharmacare covering it. 

Trevor: No. You know, you wouldn't ever go. You don't buy it. OK, so in Manitoba, you don't buy enough drugs, so you don't buy enough drugs. So, and a lot of the provincial programs are like this. So, this is a deductible. So, you know, in Manitoba, it starts April 1st. You start buying your drugs. And if you bought so let's say your deductible is a thousand dollars for a year, you buy your drugs until you get to a thousand dollars. And then after a thousand dollars, the Manitoba Health pays for your medications until the next March 31st and you start paying again. Different provinces have different systems, but that's kind of sort of how most provincial systems work and insurance companies work, kind of sort of some of the work on a deductible system, too. But yeah, if. If you know, you spend the majority of your year not paying for your you know, your opioid prescriptions, and even if you find that the cannabis ones worked better or safer or whatever, it's going to be hard pressed for you to say. But, you know, I don't want the government to pay my I'd rather pay out of pocket completely because, you know, cannabis isn't doesn't go through the same system. But anyway, OK, 

Kirk: maybe there is potential

Trevor: But it was nice, though, that the Tilray study did show on a large grand scale. The government could actually look at this and go, you know, we used to spend X amount on prescription drugs. If we instead paid for the cannabis, we might actually save money. And I think that's a good I think that's a good thing to wrap up. 

Kirk: Yeah, I haven't I haven't read the study yet, but does it talk about any biases in the study? Because you are correct, he is the vice president of a medical cannabis shop. So how did he get around the Bias's component? 

Trevor: So, some of the strengths that they got samples from twenty-one different medical clinics across five Canadian provinces. It might not be representative of the whole Canada, but, you know, I don't think that's terrible. As many of the clinics specialize in treating chronic pain, they might have over represented pain patients in in their group. 

Kirk: But then the whole the whole, the whole the whole studies on pain. So being overrepresented 

Trevor: is. Yeah, but, you know, just, you know, of if you were trying to sort of represent sort of Canadian cannabis users in general, we have 

Kirk: OK,. 

Trevor: They could have used cannabis other than that provided by Tilray and they were patients were compensated by Tilray. So there's a possibility that of a retention bias, i.e., they like the fact that they got paid something. So that's why they came back and could have possibly said sort of nice things about them when they otherwise might not have. And absolutely. A lot of a lot, if not all of the money to run the study came from Tilray. So, you know, that does throw some biases in. But, you know, I don't think those are terrible. Still limitations to have. 

Kirk: If it's still a large study and still it's still advocates to cannabis has a role to play in the opioids in the crisis we're feeling so. Yeah, well on, well done. So, you get an idea of music for this one? 

Trevor: I do not. All right. We'll leave this one for Rene. So as usual, Trevor Shewfelt I'm the pharmacist. Who are you? 

Kirk: Kirk Nyquist I'm the nurse - Reefer Medness - The Podcast. Check out our new Web page,

Trevor: All right, Kirk, that was fun. I hope everyone enjoyed that as much as I did. And we'll talk to everybody later. 

Kirk: Cheers.

Rene: All right. It's Rene back here in the studio. And another great show, guys. Thank you very much. And of course, I have a song that that we can end off the episode with, and it happens to be pretty local to Dauphin as well. Forty-five minutes north of here is Winnipegosis and in Winnipegosis is a lady named Emma Petersen who had a song out last year called Maybe Tonight. Very cool tune. Well, she just came out with another one. It's called Hurt like Hell. And that's the song for today. Cheers.