S1E1 - Why Worry? - Harm Reduction and Cannabis

"First, do no harm."  Kirk, a nurse, and Trevor, a pharmacist always make sure the treatments they offer their patients don't make the patient's lives worse.  What about cannabis?  Will it do more harm than good?  Listen to the interview with Dr. Sherry Fandry from the Addictions Foundation of Manitoba.
 
 

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Episode Transcript

Dr. Fandry: Well I'm Dr. Sherry Fandry and I'm the Knowledge Exchange Lead at the Addictions Foundation of Manitoba.  And I think that the upcoming legalization of cannabis in Canada really is a good starting point for helping people to understand I think better what they don't know currently about cannabis. I think it's a very polarized discussion with people believing that either they know everything they need to know about cannabis and it's all fine or at the other end of the spectrum that cannabis is the evil weed and you know we're going to hell. So somewhere in the middle I think is a very good opportunity for discussion about what's really going on.

Kirk: You're your doctorate, is it a Ph.D. or a medical doctor.

Dr. Fandry: It's a Ph.D. in pharmacology and toxicology.

Kirk: So your pharmacist background as a pharmacist?

Dr. Fandry: I have a bachelor's degree in pharmacy I'm careful to not make a claim of being a pharmacist as I've never practiced and I've never had a legal designation as a pharmacist. But certainly that forms the greater part of my my education.

Kirk: Okay and your Ph.D., if you don't mind me asking, what was the focus of your Ph.D.

Dr. Fandry: The focus my Ph.D. ended up being on a specific drug that is used in newborns and whether or not there were any adverse effects of this drug that had a long history of using newborns. Kind of a on a separate tack, I became very interested in how the developing animal could be affected by chemicals and also specifically around what was going on in the brain.

Kirk: OK that's that's wonderful. What I'm trying to do an introduction because people may not recognize the job of a Ph.D. is do is to formulate new knowledge about a specific thing. But in doing so that gives you a global understanding of chemicals on the brain not just the specific one you did for your Ph.D. but you have a overall understanding about how substances affect us.

Dr. Fandry: Absolutely. And, I mean my research direction ended up being looking at the late gestational effects of solvents on the developing brain and that took me into the world of addictions and substance abuse. You know it's just that people are using these and you know the vulnerable fetus can can have a number of different effects so you know one thing led to another and it led to another and brought me to the Addictions Foundation where I could really focus on on substance abuse and especially the brain link.

Dr. Fandry: Well I'll try not to use a circular definition saying that harm reduction is reducing harm from cannabis and say that we know that even in the current environment where cannabis use is illegal that people are still using it. So a pragmatic approach is to recognize that fact and try to devise strategies where people who are using anyways can keep themselves and people around them safer. So it's really about looking at a longer view of the use and looking at health and safety as the first and most important to try and how can we encourage people to use in ways that are not quite as risky.

Kirk: Okay, when I when I did my research on this and looked at why the federal government is has chosen to legalize cannabis the framework for the legislation and regulation of cannabis in Canada it really works towards the whole harm reduction side of it.

Dr. Fandry: Yes it does and definitely takes a bit of focus on on the public health approach which again is that approach that that is pragmatic but tries to look at the broader consequences. What can we do to keep our communities and our population healthier and safer. And I'm encouraged so far by the federal approach that they're looking at that public health and regulatory aspects to to maximize the health of our population at the same time trying to minimise some of the riskier effects.

Kirk: Yeah I share that as a registered nurse I really share that I think the Government's on the right track. The whole education the intervention and the guidance of use will I think help and the other side of it of course is the whole crime prevention and the billions of dollars that are being spent on cannabis alone can be redirected to other areas.

Dr. Fandry:  And my hope is that it is actually redirected to other areas that we've we've had a long history of relatively high levels of use of cannabis in Canada we're the leading or very near the leading nation in the developed world for the use of nonmedical medical cannabis already and we've really gone to that point without a lot of conversations about you know what are the real risks. Research hasn't been particularly productive. Up until this point because it's an illegal substance and we have this opportunity now to have discussions and hopefully with an open mind on both sides about you know are there benefits potential benefits to the use of cannabis. If so how good is the research or evidence for that and what are the real harms and risks and who is most likely to be vulnerable to those harms and risks.

Dr. Fandry: Well we know that selective breeding of plants can have a tremendous impact on the chemicals that are contained within the plants and there has been a highly intensive selective breeding program by illicit producers over the past 3 decades. So in nineteen sixties cannabis that would be bought on the street might have a concentration of the active ingredient THC of maybe 1 or 2 percent through the years. By the 1980s we'd be looking at concentrations of THC of between five and seven percent to the point now where cannabis is seized and analyzed through law enforcement they're regularly seeing concentrations of THC of 15 to 20 percent.  So it used to be products like hash oil and hash resin that would have THC concentrations of 25 - 30 percent. And now we achieving that with the plant itself. So that's a pretty dramatic increase in concentration over the past 40 years to get us a point now where we have very very high levels of THC and very low levels of other chemicals in the plant that might have a more beneficial effect overall.

Kirk: In the defense of the cannabis culture ,what they can say to you is well I can choose to buy one of those high THC species or I could choose to have one that is high in CBD.

Dr. Fandry: Yes and CBD cannabidiol is a substance that doesn't contribute to the high effect or the intoxicating effect of cannabis but does have some other beneficial effects in the brain that actually counteract some of the negative effects of the THC so absolutely if we've given a given an opportunity to have plants that have a more balanced profile of THC and the CBD that's to benefit most people I think who are who are involved in the cannabis culture.

Kirk:  So what is the harm reductions we could offer our patients is say okay when now when when we become legal so let's say July 2nd we have this conversation and someone saying that well I'm finding finding the cannabis is making me too dizzy you could say harm reduction. Have you tried cannabis with less THC.

Dr. Fandry: Absolutely and I think those are conversations that will be ongoing for many years after legalization does occur. You know really encouraging people to understand better where some of the negative effects of cannabis are coming from. By far the most negative effects from cannabis are from the very high THC plants you know and that's a conversation that I think legalization allows us to have.  Because it's to the benefit of illegal producers to produce very high THC content that makes it more addictive.

Dr. Fandry: Yes. And my hope is that the regulatory framework that's proposed includes analysis of the products to get a guaranteed concentration. I know that you know alcohol is a legal intoxicating substance and if I go into a liquor store I'm pretty confident that the concentration of alcohol in the wine is what is on the label. I would like to have that same confidence for somebody who is going into a cannabis retailer that the products are actually as labelled and we know from some investigative reporting that in Canada through the dispensaries that's not the case currently right that people may be claiming to sell products that are you know balanced THC and CBD or maybe claiming to sell edibles of a known concentration but when those are actually scientifically analyzed that they're not really living up to their claims.

Kirk: Right I agree with you and I think that in the framework that the federal government put out they do actually recommend that that will be one of the criteria is that the there has to be identification and labeling proper labeling for the product.

Dr. Fandry: Yeah and that's that again this is one of those harm reduction features that helps us to protect people. And you know in an educated conversation about you know what people might be consuming.

Kirk: And I think that's one of the things I like about the fact that the government has gone this route as a health care provider I will have that regulation so that I can ensure my clients understand what they're getting which is now you say you go and buy you buy your cannabis off the street. You're not getting that.

Dr. Fandry: Yeah that's I think one of the driving forces behind the Federal Government's decision to legalize is we have no assurance no quality assurance for any drugs on the street nowadays right and that you know I think we're used to thinking about that in terms of cocaine or methamphetamine as typical street drugs but I think we maybe don't give the same kind of scrutiny as consumers to cannabis products that we have no better idea of what's being sold to us with cannabis than we do with cocaine.

Dr. Fandry: Well one of the fundamental lessons I think that we have been slow to learn is that prohibition of alcohol did nothing to help reduce the harms related to alcohol use. And that was a lesson that was learned in the 20s and 30s in both Canada and the United States that you know prohibition. I have to assume was was well intentioned but did absolutely nothing beneficial for society. So in reversing that the they took a more pragmatic view that you know they would try to control alcohol use through other means over the years I don't know that we've done a particularly good job at minimizing the harms related to alcohol. We know through current research that alcohol is one of the main determinants of people being hospitalized. And you know we're very slow to come to a realization that there's more work that needs to be done in terms of helping us understand alcohol harms better.

We've done a bit better job with tobacco regulation. I think that you know after the 19th revelations in the 1960s and 70s that you know Big Tobacco had been regularly lying to people about the risks. I think that governments and society took a much firmer look at that and has done a better job of controlling tobacco access and getting information about harms of related to tobacco use to the general population. And you can see that in terms of prevalence of youth that over time tobacco prevalence has been decreasing across the board to the point where Canada has very very low levels of people who consider themselves regular smokers.

Kirk:  it is fascinating to me in my lifetime I've been nursing now about 35 years and I can remember physicians and nurses smoking on the wards and it is fascinating how we have had a complete culture change about smoking and it's interesting. You're right about alcohol but yet alcohol is not the sort of same product as smoking is smoking as you mentioned we've been lied to. I mean there's a product that was actually that was defined and created to addict somebody by a manufacturer whereas alcohol being a natural product. And I know if you can I don't know if you can make alcohol addictive like you like you can make cigarettes.

Dr. Fandry:  To a certain extent you know products that have a higher alcohol content liquors and more you know highly distilled products you know are going to be more addictive than something with a lower alcohol content that you know it's a number of servings of whatever product you're using that tends to relate to the harm. You know when you think about it. Tobacco is a natural product as well and you know the difference between you know natural organic and more synthetic drugs really isn't a big distinguishing factor in terms of how harmful they can be.  So the harms we've really done a good job of defining what are those harms related to smoking. And I think we're starting to make some progress in terms of really defining what are the health harms related to alcohol consumption other than addiction. I'm actually a bit more concerned about things like the relationship between alcohol use and cancer breast cancer even very low levels of alcohol consumption. One or two drinks a day for men or women increases the risk of breast cancer pretty significantly.

Kirk:  Those that been that information for a long time they say what is their drinks makes your heart stronger but more a risk for cancer.

Dr. Fandry: Yeah and nobody should consider starting to drink for health reasons or continuing to drink for health reasons it's just not there for us and you know we've got the lower risk alcohol use guidelines that has information there to try to prevent short term harm like getting into an accident or having an injury. And the longer term harm related to health risks like cancer and I think that the you know initial lower risk cannabis use guidelines are doing a pretty good job of looking at where those risks are and how we can minimize them.

Dr. Fandry: Well I think that the issue of secondhand smoke is a concern. I know that in Manitoba they're amending the legislation related to the Smoking Act to prohibit smoking of cannabis anywhere where cigarette smoking is not allowed. So that is going to go in tandem to try to prevent some of that secondhand exposure for people who are choosing not to use or aren't using at that moment. There are concerns there because we know that in the secondhand smoke not only are there harmful chemicals that are smoked out no matter what you're smoking. But there's also particulates that can deposit on people as well. So you know there's some risk there to be managed in terms of secondhand smoking. Some people really don't like the smell just like some people are sensitive to the smell and environment that smoke from cigarette smoking. So I think that's something that needs to be respected as well that you know users aren't impinging on you know the healthful environment of somebody around them.

Kirk: It's interesting though when you think that right now where can you smoke a cigarette or smoke cigars. Very few places. And do they even allow bars anymore to be exclusively for smokers only.

Dr. Fandry: No they don't.  And there was actually an interesting issue that arose recently in Winnipeg where private members club is installing a cigar smoking room and the the steps that they've had to go through to ensure that that they can do that legally has been has been interesting. So in general that's not something that is allowed anymore so smoking really is a matter for a person's public personal space.

Kirk: Because they do mention in the framework the federal government is saying that they would be they would be open to somebody opening up a bud bar for a lack of a better term in the sense that well you can go to a public place and smoke reefer or smoke smoke cannabis. So when you look at and this is where I was going to go with this conversation what we've learned about secondhand smoke from cigarettes is that it's harmful. Do we truly have any research that secondhand smoke from cannabis is harmful. And I asked that question because I know that at one time cigar smoking and pipe smoking those tobaccos are different than cigarettes tobacco and at one time they were rated differently for life insurance. So I guess my question is if we talk about secondhand smoke of cannabis do we truly have any research or understanding or are we just going intuitively that it's got to be bad for us.

Dr. Fandry:  I think at this point it's mostly intuitive. There again hasn't been a lot of really good research on cannabis because of the prohibition because of its legal status. So my my instinct tells me that anything that is combusted has a potential for harm for those who inhale it. So I think that at the very least there's that possibility. I think most of us also intuitively understand that secondhand cannabis smoke is intoxicating. So people who are not smoking cannabis but are in the environment where it is being smoked can end up having significant THC levels in their own bodies and they can be intoxicated as well. And you know again I think many Canadians have had firsthand experience of that phenomenon. So there's that risk as well tobacco smoking isn't intoxicating in the same way. So secondhand tobacco smoke doesn't bear that risk. Secondhand cannabis smoke does.

Kirk: That's a that's a good point. Actually I haven't thought of that. That's a very good point.

Dr. Fandry: Well and there's also the Ross Rebagliati defense of having initially had a gold medal for snowboarding in the Winter Olympics taken away from him because he tested positive for THC. And his claim was that it was secondhand smoke. I'm not sure if he stuck to that story through throughout the years. But there is a concern that people can become impaired and maybe not think about the possibility of being impaired for the purpose of driving.

Kirk:  Interesting point. That's that's that's one of the intriguing things about this whole issue that the media how are we going to as as a culture as Canada deal with this. You know we've got an instance of smoking we've got an understanding of tobacco and alcohol and now we've got this new thing called Cannabis that's entering our culture.

Dr. Fandry: As a legal entity it is very new and it's been so long since we adopted a substance that had been considered illegal into our legal culture. And that was alcohol. And it's almost 100 years that that's regulatory change was made.  So you know we do have some lessons that we can bring forward from that. But our society is so different now. I think there's still there will be questions remaining after legalization as occurred and I hope that you know people's reflection on some of those changes continues. Well after July of 2018.

Dr. Fandry:  There is a concern there and certainly the evidence does suggest that there are there is a population of people who are more vulnerable to the mental health risks associated with cannabis use. Young people are definitely more vulnerable so anybody below the age of about 16 who starts use of cannabis early is putting themselves putting themselves at risk of mental health concerns beyond just psychosis. Early youth has been associated with later anxiety problems other mental health problems. The most recently researched has been mania for bipolar disorder. You know there are some pretty strong links for a constellation of mental health issues that are related to substance using the substance especially early and certainly in a more intensive way so more frequent use psychosis the link is very strong. The research link between cannabis use especially heavy daily cannabis use and the emergence of psycho psychotic symptoms and in many instances you know what might be an initial psychotic episode could then develop into with continued cannabis use into a longer term actual diagnosis of schizophrenia.  So that's a concern it's a concern to me that young people dismiss the research that has accumulated and has become pretty definitive on that point. The highest risk is for people who have a family history of a psychotic problem like schizophrenia or even bipolar disorder. So you know at the very least we need people to understand the very direct risk for people who have that kind of family history people who smoke cannabis and have a preexisting psychotic disorder tend to experience more hospitalizations and worse outcomes. So there's a very strong link between bad mental outcomes for psychosis and the use of cannabis.

Dr. Fandry: Well it's been an ongoing attempt by researchers who are for the most part housed at the Centre for Addiction Mental Health in Toronto. But this group has been working for quite some time to take a look at a more harm reduction approach to cannabis use. So the first guidelines were published in 2011 and in the intervening time research continued and more information was available. So, they were updated this year to their current form as a lower risk cannabis use guidelines. And what they really have done is taken a look at the research evaluated the strengths of the research currently. You know what we can say with some confidence definitively and where there might be a little bit more of a grey area when they collected all of the best information that we currently have about the risk of cannabis and put them into what I think is a fairly straightforward and easy to understand set of guidelines. You know with you know it's not just don't use this substance or don't use if you're young but they're really giving the context of why early use of cannabis is more risky. Why using very high concentration THC products is more risky than using other products that are lower or that have a balanced THC and can it can have a dial profile. So I think it's a very good starting point for this discussion of you know where are the risks and how can we minimize them.

Kirk:  So has there not been enough research on cannabis to say that medicinal cannabis is a good thing.

Dr. Fandry: Short answer is No we don't have enough research at this point.  There's very little that we can say about medicinal cannabis that we can say with a certainty. There's very there's not enough well-designed well controlled medical studies that you know maybe compare standardized cannabis product to another product which is a gold standard kind of study. We simply don't have enough of them yet and there aren't very many medical conditions for which we have really conclusive proof. I have in front of me a document looking at committee's conclusions about the health effects of cannabis and including for medical purposes and really the only conclusive or substantial evidence that has been documented to this point is for the use of cannabis for chronic pain using it where there may maybe chemotherapy induced nausea and vomiting to try to control the nausea and vomiting and for them improving patients who have multiple sclerosis the perception of the spasticity you know. So in terms of high confidence research that's where we're at.

Dr. Fandry: Well in terms of medical research there are very clear and very high standards for what constitutes good research. You know very high quality search that you can have a lot of confidence in and there's certain ways of designing research studies that allow you to have more confidence in the results than maybe another study that hasn't been so well designed. So in terms of convincing me that something is has substantial benefit that's the level of research evidence that I'm looking for and that's where you know committees that convened to look at you know what is out there are really saying that a lot of those studies are lower quality. They haven't controlled for certain things that are important to understand they haven't compared their you know the cannabis to another medical therapeutic drug that has you know supposedly similar effect. So without that kind of level of proof it's hard to be confident in recommending and that's why organizations like National Physicians organizations are generally not very positive in terms of recommending medical cannabis at this point because it doesn't have a level of proof that other medical agents have.

Kirk:  That's whole controlled study qualitative versus quantitative research.

Dr. Fandry: And you know having sufficient numbers you know the fact that cannabis helped grandma with you know certain symptoms isn't a level of proof that you really want to go for in terms of recommending it more broadly.  I think there's a lot of suggestive evidence that seems positive. I'm not dismissing cannabis as a potential you know important therapeutic substance. I just don't think that the level of evidence is there to support it for the vast realm of medical conditions that currently people are promoting.

Kirk: Yeah. I again it's this whole this whole project for Trevor and I it has been amazing because we but we both came in with some preconceived understandings of cannabis and through the research we both sort of met them on one side of the fence on the other side of the fence because the research is not there but then there's overwhelming anecdotal evidence from individuals who have benefited from it.

Dr. Fandry: Yeah and I guess I come back to you know a saying that I heard when I was in graduate school that the plural of anecdote is not data. And you know like I said it's exciting there's a lot of really strong suggestions of positive medical uses for marijuana and perhaps having a country like Canada that has the capacity to do good quality medical research with legalized products maybe that's opening a really important research door for us where we can answer some of the questions that we have about therapeutic benefits about harms and risks. That's where I find a great deal of my excitement is directed that you know maybe finally we'll have some very good research.

Dr. Fandry: How much time do we have possibly possibly not enough. As I said I think that our population is pretty polarized the younger population has a myth that cannabis is organic it's herbal that it's all good and you know possibly an older population that didn't have cannabis so much when they were growing up in that culture believe that you know some of those some of the stories that we were told back in the 70s that you know cannabis is an evil weed and people are going to run amok if they use it. So as I said I think that you know the reality is somewhere in between that people who are wholeheartedly in favour of you know uninhibited cannabis use probably should put the brakes on just a little bit and consider that there are some risks and the people who think that there's absolutely no value and only harm associated with cannabis also need to take a better look at what's going on.  So one of the myths is that cannabis is harmless and we know that it does have some very specific harms and some some pretty detrimental harms. There's still a long ongoing myth that cannabis isn't addictive and it's not as addictive as a lot of drugs and addiction to cannabis tends not to carry the same kind of negative weight that some other drugs do. But we do know that about 9 percent of people who are using cannabis run that risk of becoming dependent on it. So again you know we need to have the conversations honest conversations with people you know remain open minded and willing to hear something that might not fit with their preconceptions.

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