Canada: Cut Off – How Veterans Affairs’ Clawback On Medical Marijuana Threw A Community Off-Kilter

Photo Credit: Darren Calabrese

It’s 2:30 a.m. and former soldier Chris Reid is walking briskly through torrential rain, down the main commercial strip of Oromocto, past the dormant Tim Hortons, the empty Legion parking lot and a bank of darkened windows at Veterans Affairs.

Photo Credit: Darren Calabrese

He sets a quick pace for a man with no place to be. Mr. Reid suffers from post-traumatic stress disorder and spends the early hours of most mornings walking these streets lined, in pockets, with unmistakably military cookie-cutter houses.

This town in southwestern New Brunswick draws its lifeblood from the 5th Canadian Division Support Base Gagetown. Although Oromocto is home to only about 10,000 residents, most have a military connection in the tightly bound community known for its strength and grit.

That tenacity has shown itself in the battle over veterans’ access to medical cannabis, a battle that has deepened here in recent months, to particularly dark effect.

A few years back, a small group of veterans with PTSD led the transformation of Oromocto into the global ground zero of government-funded marijuana. In 2015, former soldiers here were ordering more medical cannabis than any other veterans in Canada: $2.3-million of it, all paid for by Veterans Affairs Canada (VAC). At the time, it was the only government department using tax dollars to fund marijuana, even though there was a lack of science to support its use as a medical treatment.

Veterans’ embrace of high daily doses had a ripple effect: New Brunswick vets, who make up fewer than 5 per cent of the country’s former soldiers, billed VAC for nearly $8-million of marijuana that year, almost 40 per cent of the national total.

Now, amid a government effort, which went into full effect last May, to rein in that ballooning medical-marijuana program, Oromocto has morphed into a new ground zero – for the desperate fallout that has unfurled in the wake of that policy change: In 2017, VAC slashed the daily limit of medical cannabis it pays for by 70 per cent.

The impact was swift.

National program costs dropped by more than $12-million that fiscal year, despite a 63-per-cent increase in the number of patients. But in Oromocto, scores of veterans – who had seen their PTSD symptoms stabilize on high daily doses of marijuana – were sent reeling.

In interviews with The Globe and Mail, many said they tried to take their own lives in order to end the painful spiral into relapse. Some followed through, including one veteran who killed himself with a steak knife after just one week on a lowered dose. Many of those who persevered, however, found themselves thrust back onto a mental battlefield fraught with seemingly uncontrollable symptoms.

Mr. Reid duels with his while stalking the sleeping streets of Oromocto. Once an elite solider tapped for such high-risk jobs as protecting senior officials in conflict zones, he is a husk of his former self. The 49-year-old struggles to make eye contact. He leaves home only to grocery-shop or exercise, and hides knives around the house, he says, in case he needs to protect himself. Mr. Reid logs thousands of steps on his fitness counter in the wee hours. When daylight breaks, he retreats into isolation.

“I just haven’t been able to function,” he says, “other than just staying alive.”

Pot replaces the pills

Most soldiers who suffer from PTSD say there was not a single trigger. Instead, as their personal ledger of traumatic exposures grew, so did the realization that a mental wound had, too.

“I basically told them I feel like there’s something wrong with my head,” said Cory Pike. A father of four who was diagnosed with chronic pain and PTSD, Mr. Pike served one official tour in Afghanistan and later returned to the region for classified duties. Back home at Base Gagetown, he began contemplating suicide.

“I put myself into a hole and wouldn’t leave my house,” he said. “I just wanted to die. When you start seeing nothing but black, you don’t realize you have your children, you don’t realize you have anybody who loves you. You can only ever see negative, and then every little thing that comes up – from a hangnail to battle scars – was a problem, a big issue.”

More than 14,000 veterans receiving disability benefits from VAC have PTSD, according to numbers published by the department in late 2017. Most served abroad, as soldiers or peacekeepers, everywhere from Croatia, Bosnia, Rwanda and Haiti to Afghanistan, Pakistan, Iraq and Syria. There are also veterans with PTSD who sustained their mental injuries while working in Canada.

While for many of them recovery from PTSD is possible, the pathway is imprecise – and rife with setbacks. There is no dedicated pill to treat PTSD. Most doctors attack it with a cocktail of sleeping pills, antidepressants, anti-anxiety agents, antipsychotics, tranquillizers, benzodiazepines and so-called off-label medications designed to treat other conditions entirely. And what works for one patient may not provide relief for the next.

The goal is to stabilize symptoms, so the patient can move on to other forms of therapy.

Greg Passey is a Vancouver-based military veteran turned private-practice psychiatrist who specializes in treating PTSD. “If a person is consistently suicidal,” he said, “you’re going to use an anti-depressant. You might add a second. They need something for sleep. So right away, I’ve got three things. If they have overwhelming anxiety, I may add … Ativan. Now all of a sudden I’ve got somebody on four meds. Is that ideal? No.”

About half of his PTSD patients also suffer from chronic physical pain, which usually requires other drugs.

“That’s one of the reasons we sometimes switch over to marijuana,” Dr. Passey said. “It will often take the place of all those medications.”

Veterans commonly complain that pill regimens do not provide relief of their symptoms, or have side effects, such as impotence, that they find intolerable.

“None of the pills worked,” said Mr. Pike. “I had two handfuls of things I would take just so I could leave the house.” He began to abuse opiates, crack and cocaine, all to numb himself.

Then one day he tried smoking a joint. “I was able to function normally,” he says. “That’s how I felt. Normal.”

‘Cannabis coaches’ to the rescue

A former combat engineer, Fabian Henry developed PTSD after a 2007 deployment to Afghanistan in which his actions were responsible for the deaths of two comrades. By the time he got home to Oromocto from another deployment, this one to post-quake Haiti in 2010, he was mid-morph into an ugly, angry iteration of himself. While on nine pills a day to combat his symptoms, Mr. Henry was arrested for drunk driving and for threatening to kill the local fire chief; his marriage imploded, and custody of his kids was restricted; he attempted to choke a rescue dog he was tasked with walking; at work, he slapped a teen.

Weary and worried, Mr. Henry decided to buy marijuana on the street. After smoking his first joint, he, too, felt “normal” for the first time in years. His body relaxed. He slept that night – without nightmares.

Before long, he had spent $37,000 on something called Bubba Kush, the best marijuana he could find on the street. “I didn’t care what it cost. I’d go empty the bank,” he said. “I couldn’t get by with subpar weed.”

And, midway through 2014, he would no longer have to try. That’s when Health Canada, which regulates access to medical cannabis, instituted new rules to allow any physician, not just specialists, to prescribe – or, more technically, authorize – marijuana, and for a new, wider variety of conditions. As well, the department stopped supplying cannabis, and opened the market to commercial licensed producers.

Per-gram prices soared, from $5 to upward of $14. It was not long before VAC, which was reimbursing veterans for up to 10 grams a day, and sometimes more, saw its costs dramatically outpace its projections.

“We were taken a bit by surprise,” Michel Doiron, VAC’s assistant deputy minister overseeing the drug-benefit program, told The Globe in a recent interview. The department had not anticipated the flood of veterans newly authorized for cannabis use, and had not established spending limits, Mr. Doiron said.

A $381,000 expenditure in 2013 became $3.4-million the following year. In 2015, it was $20-million; and by 2016, nearly $60-million, making cannabis the highest-cost item in VAC’s drug-benefit program. Midway through that year, the federal auditor general slammed the department for spending such vast sums, not least because there was an absence of supporting medical evidence.

Absent from that report was one huge factor that fuelled the uptake of medical marijuana during that frenzied period: the work of Fabian Henry. The Afghanistan veteran had made a pivotal move of his own in 2014 when he co-founded the Oromocto-based Marijuana for Trauma, which helps connect veterans with doctors who prescribe cannabis and offers marijuana education as well. A subsidiary of the publicly traded Canada House Wellness Group Inc., MFT now has locations across the country, and it profits from fees paid to it by cannabis producers.

Determined to ensure veterans had access to medical marijuana, Mr. Henry and other veterans with PTSD also staffed MFT clinics as “cannabis coaches” adept at navigating VAC policies and paperwork.

Soon, pain and PTSD sufferers – Mr. Pike was among them – were coming from all over New Brunswick for high-dose authorizations. “It was saving their lives. Their wives were coming here and saying it,” Mr. Henry recalled. “People that never would have thought of cannabis were like, ‘Get my husband on that.’”

Creating a new therapeutic system

A significant number of billings originated from Fredericton-area doctor Paul Smith who, after finishing a stint on base at Gagetown, began prescribing cannabis in order to stem the number of veterans taking their own lives.

“If the pills didn’t work, many were basically on their own to find solutions … drugs and alcohol most commonly,” he said. “There are many people who don’t do well on pharmaceuticals … either it decreases their quality of life, sex drive … or they just don’t feel right.”

In 2014, Dr. Smith aligned his practice with Marijuana for Trauma (he is no longer affiliated with MFT, which expanded nationally while Dr. Smith built a new local treatment facility). MFT did not pay him – provincial rules prohibit that – but it did funnel many sick veterans through his office. Dr. Smith likely accounted for 30 per cent of all veterans’ cannabis authorizations in fiscal 2014-15.

In his early prescribing years, Dr. Smith commonly authorized veterans for a “ceiling dose” of eight or 10 daily grams. “We did that initially because we had no idea what dose worked. We were just figuring our own way out.”

There are three distinct classes of cannabis: Indica, sativa and hybrid strains. Indicas are known to be sedating. Sativas tend to be energizing. There are substrains as well. Some have high amounts of THC (which gives the euphoric “high”) and combat nausea. Others have larger proportions of CBD (which has no psychoactive effect) and control pain. The way cannabis is ingested also matters. But converting the dried cannabis that VAC pays for into edible forms, that produce longer effects, requires more volume and thus, a higher prescription.

Dr. Smith said he did not take advantage of the system; rather, he felt he was creating one.

Ed Schollenberg, registrar of the College of Physicians and Surgeons of New Brunswick, confirmed that VAC had raised concerns about the volume of Dr. Smith’s cannabis authorizations. Dr. Schollenberg’s office investigated and found nothing amiss.

In Vancouver, Dr. Passey, the psychiatrist, found that most patients to whom he prescribed cannabis were able to take fewer pharmaceuticals.

In fact, treatment data collected by VAC and obtained by The Globe and Mail show that the department spent about $91.5-million on prescription drugs in 2012-13, when medical marijuana cost just $284,000. By 2015-16, marijuana costs rang up at $20.5-million, but prescription-drug costs dropped by a similar amount, to a total of $71-million.

‘They’re running a double standard here’

As veterans’ medical-marijuana use – and VAC’s costs – climbed, so did concerns among department staff who believed the program had grown too elastic.

When VAC began paying for cannabis in 2008, the move drew worldwide attention; demand for cannabis treatment was on the rise. And courts had already compelled Health Canada to provide reasonable access to marijuana for medical purposes. But the lack of supporting science – the Canadian Medical Association, for one, says there is “insufficient evidence on risks and benefits”’ – had been taken as grounds in most countries not to loosen restrictions or, by extension, devote tax dollars to fund it.

At Veterans Affairs itself, according to internal documents examined by the federal auditor general, the decision to adopt medical marijuana was taken “at the senior management level,” although the auditor general was “unable to determine” why.

Meanwhile, hundreds of internal documents and e-mails obtained by The Globe through Access to Information requests show that VAC’s top doctor raised red flags during the years that costs rose most quickly.

“The scientific medical literature reveals that there is no relevant evidence to support the use of dried cannabis for medical treatment of any condition,” Cyd Courchesne, VAC’s chief medical officer, wrote in a 2015 briefing note labeled “Advice to Minister.” She went on to say that the department’s policy of paying for 10 daily grams was made with “no medical input,” and she flagged studies associating cannabis with memory loss, lung cancer and even psychosis. “Medical treatments and benefits should follow the principles of evidence-based medicine,” she wrote.

In an interview with The Globe last fall, Mr. Doiron, the assistant deputy minister, said VAC was aware that funding medical marijuana made it an outlier among government departments that pay for health services. “We’ve been told we’re blazing a trail, and a lot of people are looking at Veterans Affairs – for good or for bad,” he acknowledged.

But, he said, the department’s “primary focus is on the health of the veteran. If this gets you on your feet, or out of your basement … and gets you back as an employed person of society … we want the veteran to get better.” Added Mr. Doiron: “You have to remember, at VAC, we are really only a payer. It is the responsibility of the … family doctor, specialist … to do the diagnostics and the prescribing.”

It has yet to be scientifically determined if cannabis is an effective treatment for PTSD. Both Canada and the United States have recently announced plans for studies on the subject. But Zach Walsh, the lead researcher in Canada’s first randomized controlled trial, taking place at UBC in partnership with cannabis producer Tilray, argues that “we need to listen to the patients. They’re saying that it’s having extremely positive effects. I agree that we want the best evidence,” but important, as well, is “a compassionate approach to treating patients.”

That appeal has not been enough to convince most doctors, including those who work inside the national network of Operational Stress Injury clinics that treat military, defense and police workers.

Anthony Njoku, a psychiatrist at the Fredericton OSI clinic, said that, in agreeing to pay for cannabis, VAC put an unfair onus on doctors who experienced pressure from their patients to authorize a treatment most knew little about. “It’s not how we’re trained – the point is, above all, do no harm,” Dr. Njoku said, adding that doctors also have no way to know what dosage or strain to use.

Although the team Dr. Njoku works with did briefly issue some authorizations for cannabis – “I really have nothing against the veterans who are reaching out for anything that may be the next salvation” – he says they ceased doing so in early 2017. “The demand,” he said, “far outstripped the rationale.”

Still, in the 10 years since VAC began paying for cannabis, more than 7,000 veterans have turned to the treatment.

And yet Dr. Njoku feels the medical-marijuana program has always been troubled. “There was no well-thought-out strategy to it,” he said. “It was mishandled from the get-go.”

By the time VAC’s bill for marijuana hit $60-million in 2016 – almost 60-per-cent more than projected – the auditor general had already admonished it for mismanagement. A cost-containment strategy was recommended in the spring of that year, and by late fall a new policy was in place for new medical-cannabis patients, who were told VAC would cover just three daily grams.

At the time, more than half of the veterans in the program were authorized for higher doses. They were notified by VAC that they, too, would be cut to three grams as of May, 2017. Exemptions would require visits to a specialist, and long waits.

Mr. Doiron said the changes have shored up VAC’s “credibility” – and that they were not about money. “The first driver is: What is the science saying when it comes to the use of cannabis for medical purposes? You hear it has helped people, but that’s anecdotally.”

That explanation angers Vancouver’s Dr. Passey. “People say, ‘Oh, it’s anecdotal’ as a way of diminishing exactly what’s being observed. But with medicine, everything starts with a test case.” He added: “There are a number of medications that are used … where there has been no research to support the use of that type of medication with PTSD. Veterans Affairs has no problem funding those … So they’re running a double standard here.”

He does not disagree with the idea of employing greater caution, but points to the effects on patients and families when veterans who are stable on high doses are forced to endure sudden cuts. More than 2,500 veterans were affected by the reduction.

“Can you imagine,” he asked, “being on 10 mg of morphine every day and then being told we’re going to cold-turkey you down to 3 mg, not for any medical reason but for a financial one? It was an absolutely asinine decision.”

Dr. Smith, who has more than 2,000 active files, describes what he sees as “a bias toward cutting back on something that was politically unpopular” yet is “a significant stabilizing therapy to allow other therapies to take place.”

He added: “If there’s a quality of life, there’s a reason to live.”

‘Every day I want to die’

George Martin did not leave a note.

In the hours before the retired warrant officer slipped unnoticed from his rural Geary, N.B., house one evening last May, carrying a kitchen steak knife, he phoned each of his three sons. He told his boys, grown men in the midst of their own military careers, that he loved them.

To his son Todd, who lived just down the road, the call did not raise any alarms. Both men had suffered from PTSD, and his father’s moods had grown more volatile over the previous month as he worried about the impact of having his daily 10 grams of cannabis cut down to three.

The prescription pills George tried before marijuana had failed: He was left with anger so overwhelming that he once nearly ripped a car door off its hinge. He ended up in the hospital for psychiatric observation. The switch to cannabis, Todd Martin said, leveled his father out, relaxed his clenched jaw, and removed the lines of fury from his face.

When word of the cuts came, the elder Martin warned his family and close friends that he would “rather be dead than back on pills.”

He tried to manage on a reduced dosage of cannabis for a week, noticeably isolating himself from loved ones, before he began making those final calls to his sons.

“He’s like, ‘I love ya,’ ” Todd said. “Didn’t think nothin’ of it.”

Then, after dark, Todd’s mother called. She’d gone to get a piece of fish to cook for dinner and returned to find her husband gone. Todd spent most of the night combing the woods behind their house, calling out for his dad.

The next morning, exactly one week after Veterans Affairs had fully implemented its new policy, George’s body was found – as it turns out, in his own back yard. He had stabbed himself in the chest and neck.

Veterans Affairs ruled that his death was due to “factors associated with” PTSD.

In an e-mailed statement, VAC said the department “cannot corroborate” links between any suicides and the marijuana policy change. “Suicide is a complex issue and rarely is it attributable to one factor only,” it read.

More than a dozen veterans interviewed by The Globe in Oromocto said their lives have been damaged in the year since VAC instituted its new daily limits on medical cannabis.

Mr. Pike, the Afghanistan veteran, told The Globe that “coming off of 10 grams … almost killed me,” and he has made at least one additional attempt on his life. The plan was thwarted, and, in fact, Mr. Pike later had his 10-gram authorization reinstated. But he is still reeling from the psychological trough in which he found himself.

“Most of the time, when I look in the mirror, I am covered in blood,” he said in an earlier interview. “And every day I want to die.”

Dr. Njoku acknowledges there have been several deaths in the community since the policy change, but does not believe lower doses of marijuana are to blame.

“We certainly have had a higher number of veterans being admitted to hospital involuntarily – people who have to be forcibly kept in hospital because they have become so much more unwell,” said Dr. Njoku, of the Fredericton OSI clinic. He believes it was the higher doses that did the harm.

When asked recently about the department’s new policy, VAC’s Dr. Courchesne told The Globe: “The position we have taken is the responsible one. We’ve done our due diligence by reviewing our policy and following the best guidelines that are out there right now.”

About 1,200 vets have received exemptions to use more than three grams per day again. More than 400 have had their applications rejected.

However, the doctors who specialize in authorizing cannabis for PTSD sufferers say that the way VAC lessened access to the amounts of cannabis on which many grew stable threw an entire community painfully off-kilter.

Ron Forrest, a 62-year-old grandfather with 28 years of military service, had been feeling psychologically stable on a 10-gram-a-day cannabis regimen for about 18 months when he was cut down to three grams last May. Suffering both PTSD and chronic pain, Mr. Forrest had used three to four grams’ worth of his allotment to treat pain in his back and knees. The remaining allotment was split between strains he smoked for sleep and for daytime energy.

Under the three-gram limit, he was forced each day to choose which ailments to treat – and which to endure. “I had to get up in the morning and decide if it was pain or brain. What do I feed today? It was devastating,” he said. “It increased my anxiety and I was back down again to three or four hours’ sleep a night. I was very, very short-tempered.”

His marriage ended.

After five difficult months, Mr. Forrest received the special exemption allowing him to revert to 10 grams a day. As he sees it, the potential long-term health effects pale when compared to the reality of life without enough cannabis.

“I’d be dead,” he said. “I would have killed myself by now.”