So, I'm Melissa Snyder-Adler, I am an addiction medicine physician, I'm a medical review officer, and the last, and I'm from Canada, most importantly for this talk, the last five, seven years, I feel like all I've been asked to do is speak about cannabis in the workplace and the impacts of cannabis and the legalization, and I was thinking, oh, you know, five years of legalization in Canada, and now I'm going to be good except that everything is resurfacing again because of A, what's happening in the States, what's happening all over the world, and C, because we still haven't figured it out in Canada. So although I'm going to go through what we have done and what we can do and things to consider, we do not have all the answers, and I'm still consistently asked to go into workplaces and say to people, you know, or when people are asking me, what can we do, how do we deal with this, how do we manage it? All right, so I'll just start off with some disclosures. As I said, I am the chief medical review officer for DriverCheck, which is a TPA in Canada. I have done some speaking, not for a while, but with Endivier, which produces a medication for opioid agonist treatment, and that is really it, nothing really to do at all with cannabis, medical cannabis, or anything like that. This is everything that we're going to go through. So I could speak for hours about this, but I do want to leave time for questions because I think it's such an important topic, and I think there are so many people that struggle with both medical cannabis and recreational, so I do want to hit on both. But just so that you can put things into perspective, I'm not going to go through a long time about our history in Canada, but we have been going through, from a medical cannabis perspective, we've had legalization since 2001, and we've had different iterations of it, and you could grow your own, you can't grow your own, you have to buy from our government, you can buy from other places. And I'll tell you what we have now because I actually think from a medical cannabis perspective it works, but our legalization was announced in 2016, and it has been since then that workplaces have been struggling in figuring out how to deal with cannabis, recreational cannabis. But it's also been since then that people have realized that cannabis is, what I hear all the time, don't you know it's legal? It's fine. So somehow around 2016 in Canada, cannabis became non-impairing, non-problematic, it's fine to use it because it's legal, there is no issue at all. And I just want to kind of go through some of that. I will test you on this afterwards. This is all of our changes that we've had in medical cannabis, which I'm not going to go through except to tell you how we do it now because we do differentiate from an MRO perspective, not for non-DOT, and as well in sort of legally, medical and recreational, even though we have both. So our medical cannabis right now, the way it's supposed to be, is that you get an authorization from a healthcare provider, it can be a nurse practitioner or a physician in Canada. And then you have to register with what is called a Health Canada licensed producer. There are over 400 of them. We started off only with a handful, now we have many more. And really, you register with them, you purchase your medical cannabis through them, and they mail it to you. We do not have any stores where you can walk in with your medical authorization to purchase. So why is that important? It is important because we have the ability as MROs and as physicians to ask people not only for their medical card, but for invoices. Because if you're not purchasing it through the medical system, it's not medical cannabis. You can have an authorization, and you can go to the store, and you can buy whatever you want to, but that's kind of like saying, well, my doctor prescribes me Tylenol 3s, but my mother-in-law gets them, and I just get them from her. So if you're not getting them and taking it as your healthcare provider tells you in the dose and everything else, then how do we actually know what you are using, how you're being managed, et cetera? And so that's how we differentiate it. It's a little bit different for probably most of you, because I know often I just hear from clients here that, well, they have a medical card, but they can get it anywhere they want to. And so it's a bit of a, in some places, it's a bit of a problem. All right. In 2019, 2018, we legalized cannabis, but in 2019, we made the availability of concentrates, edibles, and oils. And so what does that mean? There is a huge, and this is probably no different than most of you, availability of very, very, very high dose THC products. Very high dose, 90%, 80%. And there are many people that that is what they're using. And in some of our recreational stores, it is almost impossible to find really low dose THC. Just, you go in there, and I went in because I was very curious, and said, I just want a low dose THC product. I just want to see what you guys have. And the lowest dose THC product that they had was a small little joint, which was rolled. And it was, their lowest was 18% THC. Okay. Compare that to all of our studies that were done over the last number of years, especially the ones that were done in the US, where the THC concentration was three to 5%, because that's the only thing that you can get. Now, you can use more of it to get a higher number of milligrams of THC. But the truth is, if I'm using a gram of 20%, a gram of 2%, a gram of 90%, we are talking about totally different things. And even, and I don't like to compare cannabis to alcohol, but even if we compare cannabis to alcohol, that would be like saying, well, I'm drinking a glass of beer, or I'm drinking a glass of vodka. They are not the same thing. You're going to have different lengths of time of impairment, and intensity of impairment. The nature and the duration of impairment changes as the concentration of the drug increases in your body. End of story. Doesn't matter what drug we're talking about. So there is an issue with that. Just to put it in perspective, because I don't actually think that our numbers are any different than anywhere in the US. So just to take a, just so that I know, how many people are working in a state with legalized recreational cannabis right now? Okay. Keep your hands up for a second. How many are working in a state where they are thinking about legalizing? Okay. How many of you have kind of figured out how to deal with this in the workplace? Okay. I'm with you right there. All right. So what do we see here? We actually have had an increase over the number of years, and they are statistically significant of people using cannabis. I don't think it's a huge leap of anything that anybody would expect, that if you have legalized cannabis, if it's acceptable, if it's easily accessible, then you're going to have more people using cannabis. But this is really what we have here. We do a survey every year. We've done it since legalization of how many people use cannabis, where they purchase it from, what products they're using, et cetera, et cetera, et cetera. And from that, we get some decent information. And so obviously, not surprisingly, our highest numbers are in the 20 to 24-year-olds, actually higher than teens, which is probably understandable, but it's legal in Canada as of 19, although I don't think legalization or being legal makes a difference with teenage use of anything. But nonetheless, that's our highest percentage of people using. But you can see that the averages over the years have gone up, and we are somewhere now, let's see, the overall is the light blue, we are somewhere between 20 and 30%, which is a lot. I think it's 26% across Canada, and the provinces differ. Some provinces are up to 36% of population using cannabis. When we ask about driving and cannabis, and I use this from a workplace perspective, although we do have a question in our survey about, do you use cannabis before work? And when they say before work, they mean within two hours or at work. And those numbers are also much higher than I would like them to be, but they didn't include it in this last year's data that I had yet to get my hands on. I usually like to get the Excel spreadsheets of the data so I can actually see. But nonetheless, this is the number of people driving within two hours of using cannabis, or driving while using cannabis, I suppose. And you can see that the numbers are pretty staggering. But what is more important in how we relate this to the workplace is actually how often people are using. So because from a workplace perspective, if you use once a month or once every few months, your risk in the workplace is going to be lower than if you use on a daily basis. You use on a daily basis, and probably somehow, maybe, it's going to impact impairment, which we'll talk about. But that's a much higher risk. If we look at here, 32% of people who say that they use cannabis use it three or more days per week. Well, I will say using three or more days per week, and we'll talk about it for a moment, will certainly impact the workplace. Five or more days per week is significantly going to impact the workplace, and that is 23% of our population of people who use cannabis. Not the population, people who use cannabis. But that's a big number. I mean, we look at alcohol, daily alcohol use is not at 23% in Canada, it's lower, using it five or more days per week. And so it is a problem, it's becoming much more acceptable, and more people are using it. As an MRO now, when I have a THC positive, and I now say to them, test positive for THC, did you use on the day of the test or the night before? Because I used to say, how long before the test did you use? But now, I just say, did you use that day or the night before? Oh, no, no, no, no, no, it wasn't that morning, it was the night before. Almost invariably, everybody tells me that they use cannabis the night before. I have very few people that say to me, no, no, no, I stopped a couple of weeks ago. It's still positive in my urine, but I stopped a couple of weeks ago. I have a few for a couple of companies, but most of my companies, most of the people will tell me that they use the night before, which is a problem. We also know from the Quest data that in the states where there's legalized cannabis, there are higher rates than average of positivity for THC, and in the states with no legalization, they are lower. Where there's more availability, it's more acceptable, you're going to have more people using it, it's becoming more of a problem in the workplace. What does all of this mean for safety? These are all mostly of the areas where cannabis can affect from an impairment perspective. The big question is not, does it affect impairment? The big question is, how long does impairment last? That's what I get asked all the time. I think everybody can agree, even when I do a lot of arbitrations and court cases as an expert, and even the usually unions experts will agree that there is impairment with cannabis, although they tell me that it's only for a couple hours, and so we're all good. You can use whatever you want to, and then there's no impairment, you're all fine, it's a light switch, your brain goes on when you use, or off when you use cannabis, or on, or however you want to say it, and then it's the other way, two hours later, three hours later, four hours later, end of story, case closed, and then I say, well, what about edibles? Oh yeah, no, no, those would longer, but I'm only talking about smoke cannabis. And I say, well, okay, but you're only talking about smoke cannabis, but aren't there people that use edibles? Yeah, yeah, yeah, so their impairment will last longer, okay, so how do I deal with that in the workplace? Well, no, we only have to worry about people that smoke, I'm not sure why, this is sort of a common thing. But what I want to really emphasize here is that there is a difference between intoxication and impairment. So the Canadian, what is it, the Canadian Society of Forensic Sciences, and I'm sure there are lots of different definitions, but they define impairment as a decreased ability to perform a task, differentiating that from intoxication, which are the signs, visible signs and symptoms of the drug use. So if I were to now smoke cannabis, you would probably all notice it, I would have visible signs because I don't use it, it's just not my thing. And so you would notice that, I would be intoxicated, I'd be high, you would see the signs of it. However, a few hours later, that's going to dissipate, but that doesn't mean that I'm non-impaired, it's kind of like alcohol, I can be drunk, then I can be hungover, and I will say that people who are hungover and feeling really unwell are impaired. You're not going to be able to function the same way, and it's the same thing with cannabis. And so while there are a lot of studies that look at impairment, or they talk about impairment, they're really talking about intoxication, they're really talking about the overt signs and symptoms of that initial period where we have high levels of THC in the blood. So in Canada, our version of ACOM is OMAC, Occupational Environmental Medical Association of Canada, and they came out with a position statement right around the time of legalization with respect to the use of cannabis, after putting experts together, reviewing all of the data, doing a review of all of that, and taking a look at, well, what time frame are we talking about here? What do we tell workplaces? We don't have a federal government, despite the fact that they legalize cannabis, that has anything to say about what workplaces should do. Safety sensitive, safety critical, other than airline pilots, other than Transport Canada, which has said something about our aviation industry, we have nothing else. Not for mining, not for, I mean, we have Mining Act, but it doesn't talk so much about cannabis per se. We just don't have federal regulations. And so we needed something to say what are workplaces with safety sensitive workplaces supposed to say to their individuals about cannabis use, and 24 hours is what they came up with. And that's where we still are, we haven't changed it. And we'll talk about why that is in a moment. This is the most up-to-date one, which now doesn't say 24 to 48 hours from AECOM, but it does talk about the ability for employers to be able to tell their employees that they should not be using cannabis for a particular period of time. What troubles me a little bit is that it uses eight to 12 hours, and now I have union experts saying, see, even they say eight to 12 hours, I'm like, no, no, no, they say at least eight to 12 hours, but that doesn't mean that it should only be eight to 12 hours. You are allowed to go longer. But nonetheless, I think the point of this was just more to be able to say that, you know, even though it's legal, being able to say nothing is a problem, right? Just because it's legal does not take away the impairing parts of it. Just like alcohol. Alcohol is legal. I don't think anyone will argue that there is no impairment from alcohol because it's legal. You can drink whenever you want to. And what I find most interesting is this whole idea of off-duty use. So I wouldn't want people having 12 beers off-duty, okay? I don't even want you having two in the morning when you are off-duty right before you go to work. So this whole idea of, you know, you can't prohibit people from using cannabis off-duty, well, really? I mean, I know that you guys weren't the ones who made up these laws, but anyways, I find it troubling because it's the off-duty use of any substance, because off-duty could literally be as you're walking into work, that could be problematic. But I don't have to tell you that. All right. I do want to go over a couple studies because these are the ones that people point to where they talk about the fact that impairment only lasts for five hours or impairment only lasts for six hours. End of story. So that in the workplace, we don't need to worry about it because it's only for six hours. So McCartney is a big one. It's a great study. It's a very, very, very well-done study. It's a meta-analysis, 78 publications, lots of outcomes, over 1,500. And they attempted to look at the magnitude and duration of impairment, except for a few things. They only looked at less than 20, studies that looked at less than 12 hours of assessments. So this isn't really magnitude and duration of impairment. This is really magnitude and duration of intoxication because they didn't look at anything beyond 12 hours. So you can't say that there's no impairment beyond 12 hours if you don't assess that. Okay. So that's the first thing. The second thing is that they looked at studies that used 20 milligrams of THC as their highest. So they have 10 milligrams and 20 milligrams. They put it all together and put it up to 20 milligrams. So they came up with all of these statistical analysis to come up with a timeframe of impairment based on 20 milligrams of THC. What is 20 milligrams of THC? So for example, you use one gram of 20% THC, that is 200 milligrams of THC. 20 milligrams of THC is a very low dose in today's standards. Not in the standards maybe before. And then I get into the whole thing, well, people take in the, you know, you can change how you breathe in and you can take more or less in. You titrate your use. Yes, you can titrate your use to an effect. But just like all other drugs, the more you use, the more you're tolerant to it, the more you need to use to feel the effect, and this goes on and on and on. And so yes, I agree. If you give me, who does not smoke cannabis, a 20% joint, I'm barely going to take it in because I don't use cannabis. So I'm not going to really take it in. You take somebody else that uses on a daily basis and you give it to them and it's like they may take it in stronger and get more THC in their body. But 20 milligrams is still a low dose. That's the other thing. The other thing is that they only assess studies that looked at single doses. Now if you ask people, there are many people that use right when they get home from work and then they use again before bed. They may use one joint, they may use two joints, they may smoke over a period of time. But that is not a single dose. And so the findings or what they concluded here was that the average is five hours for smoking and seven to eight hours for ingestion, up to seven to eight hours actually for smoking. So up to, right? That's what we may be concerned with is the up to, and 11 to 12 for edibles. But what is most important again is that this does not mean that there's no impairment beyond 12 hours. This does not mean that people that use higher doses more often and are regular users, because these are only occasional users using less than three times per month. So this is likely not applicable to the 25% of the population that is, or more, that is using cannabis on a very regular basis. We have another really good review. I think they're actually Canadian, plug in for that. And it was a systematic review where they looked at over 43,000 subjects. And they looked at all of these studies to see, you know, does impairment go beyond the acute intoxication phase? And what they basically found was, absolutely. We have great evidence of prolonged impairment, however, the studies tend to be in those who use cannabis on a daily, regular, frequent basis. If you are a very occasional user once a month, the chance of you having prolonged impairment that lasts for days to weeks is lower, likely not going to happen. But again, we have 25% of the people that are using cannabis using it on a daily basis. They're the ones who are at risk of prolonged impairment. And why does it get tricky in the literature? And why do we have all of these debates back and forth? Because you take a chronic user who uses every single day, who probably uses a higher dose because they've become tolerant to it. And now you put them into a randomized control trial and you give them 20 milligrams of THC. Is there a, you know, is anybody like questioning why it is that they have no symptoms? I hear, well, they are not even impaired at all. Of course they're not, because you're giving them a tiny dose. That's like taking a person who is used to drinking 24, you know, 24 beers a day and giving them one beer. Do you think that they're actually going to have any signs or symptoms of intoxication, probably not because they're tolerant, but that doesn't mean that they're not impaired. And they are the ones who, when you test them, in all of our studies, when you look at them and you test them, two weeks later, three weeks later, they start to perform better on complex cognitive tasks. When we do cognitive testing on them at the beginning, then I hear the whole thing, oh, well, maybe they were like this before, and that's why they use cannabis every day, okay? Because I hear this. These studies are not randomized controlled trials, blah, blah, blah, blah, blah, therefore we can't depend on them, okay, except why did they improve after one week or two weeks or three weeks? If they improved, then we can say that now that impairment is decreasing. And so we're still in a debate. The questions are not answered. So where does that leave us? It leaves us with the fact that we absolutely have a risk of impairment that goes beyond the four to six hours that people talk about. You are likely not going to be intoxicated, and from a personal driving vehicle, meaning you're driving a personal vehicle that is different than performing safety sensitive tasks, why? Because the more complex the task, the more cognitive power it takes in order for you to perform that, right? It's like sometimes you drive and you get somewhere and you're like, I don't even remember driving here, right? Like I'm pretty sure I didn't run a red light, but I barely remember driving, right? We've all been through that. When you do something so simple that you do over and over and over again, we don't need to do it with much thought. But safety sensitive work, safety critical work is different. It may be okay until there's an injury, an accident, something that happens that is out of the ordinary, and that is when you need to have those complex faculties about you. And so using what we use for driving a motor vehicle for that six hours or eight hours or whatever they talk may not be applicable for safety sensitive work. And when we put everything together, and we look at 25% of the population using every single day, being at risk for prolonged impairment that lasts significantly longer than a few hours, and we look at the rest of the people that, okay, fine, maybe you don't. Where do we put that balance? 24 hours is probably good, but it may need to be longer. I have some industries that will say to me, yeah, I can't take any impairment. It's so safety critical that I don't want anybody at risk at all. If you don't want anybody at risk at all, we need to go out to 28 days. If you say, well, I just don't want people to be intoxicated, they're not doing anything so, whatever, and I'm okay with intoxication, then 12 hours is probably where you lie. And I don't think there's necessarily a right answer that is across the board fine for everybody because safety sensitive is not just one definition, right? So we have different levels. We don't put it into that, but really we do. So certain activities are more what we may consider safety critical. Certain ones, you know, the chance of, you know, if you have kind of low level impairment impacting and it causing an incident or an accident may be lower. We don't have studies to really talk about that, but that is the truth of it. I'm going to go through a couple more just very quickly just to give you a flavor of what we're seeing here. This is a study that was done also in Canada of workers and they divided up between safety sensitive and non-safety sensitive workers so we have a good idea about what we're seeing in safety sensitive workplaces. And they asked about what they call workplace use, which is again, two hours before or during work. And they asked about accidents, incidents, or injuries. And they looked at that and they basically found that people that use before work, meaning within two hours or at work, had a two-fold increased risk of workplace injury. Interestingly, the people that use, but what they call non-workplace use, meaning you don't use within two hours, did not have a statistically significant increased risk of injury. However, to me, that little 23.3 there needs to be broken down because non-workplace use could be 12 hours, 24 hours, or 24 days. And if we don't differentiate that, then we don't actually know where that line is. They drew a line at the two hours, but I don't actually know that if you use six hours, 12 hours, 24 hours, that you don't have an increased risk of injury. So this is helpful. But I think we can all agree that you probably shouldn't be using cannabis within two hours of work or at work. But I just wanted to put that out there. We've seen, and you guys have seen as well, an increased number of people that are involved in traffic accidents with respect to cannabis. And we've seen an increase in legalization, what we call commercialization with the availability of the high dose stuff. And this just kind of speaks to that. So I'm not going to go over it because I don't think it's... But significant increases with people that have THC involved in their injuries or accidents from a car accident perspective. But what I want to get to is, okay, so now what? We know the risks. We kind of maybe can have an idea of where we want to put the risk of impairment for the workplace. And that may be guided by what the regulations are and the laws in your particular state. So I'm not going to tell anybody where to put it, but how do we utilize testing and how can we change it a bit to work within what we have? So in Canada, it's all over the place. Meaning we have people that are like, yep, no, we're okay with 24 hours. We have a few industries that are saying, no, we need 28 days, which is essentially zero tolerance. But let's just say 28 days, because we can't take any risk because of the types of duties that they're performing. And we have other ones that are saying, because they're negotiating with unions, yeah, that's just not going to work. You need to prove to me that they are impaired, which is a very hard task. We can't really do that with drug testing, but we'll talk about impairment testing in a moment. But it can be done. What I tell people is this. There's lots of different ways of doing drug testing. And the length of time that you are detecting changes based on what you are testing. If it's hair, it's a few months. If it's urine, it could be a few days if you don't really use, but it certainly could be many, many weeks. Oral fluid, and we're going to talk more about that in a moment, can be up to 24 hours or so. Breath testing, very short window of detection, a few hours. If you really just want to know if they use within a few hours, good test. But I would say that I'm concerned, and I'm looking into it a little bit more, that it's not going to even pick it up for the short period of time that we've seen that even occasional users are impaired for. And then I just wrote down there what we see with acute and residual impairment. So urine testing, I used to say it's the gold standard. I want to now lean towards oral fluid being the gold standard, but it still is there. What is the problem with it? It's very easy to cheat. It's very easy to drink a lot of water. It's very easy to take your levels and lower them. But more importantly, I get the, well, the level was 3,000. They must be impaired. And I say, maybe and maybe not. I can't tell you when they use cannabis based on a urine test. I don't care how high it is or how low it is. I've seen levels at 15 nanograms per mil, and I've said to somebody, did you use that day or the night before, and they'll say, no, no, I used that morning. I use every morning. I use every night. And their levels are low, so I can't explain it. But even looking at the creatinine doesn't really make sense to me, but that is what it is. And the other thing is that I've seen negative urines with a positive oral fluid. They either cheated on their urine or they used so close before the time of the test and they don't normally use cannabis that, you know, that they haven't had time to produce the metabolite to excrete it in the urine. Probably not likely. Probably cheating. And, you know, there's lots of ways to cheat. If you haven't seen The Wiznator, it's about my favorite product. It now comes in skin colors that match everybody's skin color, and it comes with a bladder that can be warmed up that you can put your fake urine in that you could also buy from them. So, you know, I will sometimes talk to people about this, and they're like, no, no, no. No one's doing that. Oh, yeah. If you don't think they're cheating, it's kind of like going to a high school and saying you don't think that there's a dealer at the high school. There are dealers at high schools. There are dealers that deal at workplaces and work sites ways to cheat on your urine test. The good thing about oral fluid is it's all observed. I'm not saying that there's no way to tamper with it, but it is all observed. So the chance of tampering is significantly less. We wait 10 minutes after an oral fluid test. We wait for them to come in and wait the 10 minutes so that anything in the oral cavity is sort of absorbed if they've tried to put something in there, and people do try to cheat. There's lots of things out there you could read online and find. I'm not saying there's no way to cheat, it's just less likely. We in Canada, however, have three different confirmation cutoff levels for THC. Why is that important? We often, and I come to talks and I hear, oh, well oral fluid testing lasts for 24 hours. And I say, yes, if you're using a confirmation cutoff of two nanograms per mil. But if you raise the confirmation cutoff level, we've now narrowed the timeframe of detection. And you can go up as high as you want and narrow it as much as you want, because really when you use cannabis, smoking it or ingesting it or an oil in your mouth, you have exceptionally high levels of THC in your oral fluid. It coats it. It's there. The oral fluid is picking up only what's in your mouth. It doesn't cross over like other drugs from the plasma or the blood into the oral fluid. It is simply what stays there after you've used it. So if you use it rectally, you're going to have a negative oral fluid test. Although I would say that probably most people don't use cannabis rectally, but just to kind of put that out there, you are not going to test positive unless it's been in your mouth. So even a nose spray will get into your mouth. That will test positive. An edible will test positive. An oil will test positive. Smoked or vaporized will test positive. You have very, very, very high levels for the first few hours. I think I have a... Hold on. I'm going to go ahead for a second. Maybe I don't. You have very... I may... We may conjure. I can't remember if I put it in here. Very, very, very high levels at the beginning. The levels decrease 95% within three hours. Okay. So you may start out with 1,000 or 2,000 nanograms per mil. And I had somebody that say, well, the level was 923. That must be an error. I'm like, no. They just used really close to the timeframe of the collection. So when you did a reasonable cause because you thought they smelled like cannabis, they'd probably just finished smoking it. You brought them for their test, and now you have this really high level. That's what it is. But within three hours, it drops, and then it continues to drop hour over hour after that. It will hover around two or three for a little while, and that's why you get some people that will say, well, it could be 24 hours or a little bit longer. Oh, whoops. Sorry. This is the one I want. But if we raise the confirmation cutoff level, we decrease that timeframe. So we in Canada have three options. Two, and I say it's about 24 hours. It could be longer for heavy users of cannabis who use daily. Five nanograms per mil, which I have a whole long story of where that came out from, but I'm not gonna go into it. It was sort of a negotiated thing between two and 10. So they came up with five. And so I would say, I always say, well, that lasts somewhere between 12 hours and 24 hours. When we look at the studies that show us the raw data, it's probably in and around 16, 18 hours of detection. Not bad. If you're a chronic user, you may get a little bit more than that, but we're not going beyond 24 hours with that confirmation cutoff level. And 10, which is widely used in some transportation in some provinces in Canada, is about 12 hours. Can you test longer? Yes. If you're a chronic heavy user of cannabis, it can be 14 hours or 16 hours, but I will also argue that you are probably impaired for longer than that. And so again, it's that balancing act. Is everybody unimpaired at 12 or 14 hours? No. Is everybody impaired at 24 hours if you're using two? No. So it's just where you want to put that balance between who you're detecting from a risk perspective, and that's really what it comes down to. Are you going to detect people with THC in their oil fluid who are not impaired? Maybe if you're using a low cutoff level. And are you going to miss people if you use a higher cutoff level? Yes. And that's the decision point. And that really depends on what the positions are, what the duties are, what the industry is, and what the regulations are in your particular state, or if you're from Canada, in Canada, which we don't have any. But as you see, as you increase the confirmation level, you are narrowing the timeframe. And so when people are very concerned with being able to pick up something that is not a metabolite, because this is not a metabolite, this is Delta-9-THC, active THC, this is not a metabolite test. So for California and Washington, where you cannot test for the metabolite of THC, oil fluid works well for that. When they talk about off-duty use, well, maybe you have to narrow that window by raising the confirmation cutoff level. So ask your labs about it, because it's a great test, and it gives us a lot of information. And this is how we have gotten around a lot of our industries and a lot of our decisions about what we are doing and how we are managing in the workplace. And I tell everybody, I'm not going to tell you what cutoff level to use. We need all of the factors, we need to figure this all out together. Where are you putting that risk balance? What do you want to tell your employees with respect to use of cannabis? How long before work do you feel it's important for them not to use cannabis? Ideally, nobody would use any drug ever. Everybody would get a good night's sleep. Nobody would take any over-the-counter medications. Nobody would have any children or parents or whoever that keep them up at night. You know, we would all live these very... Nobody would eat unhealthy. Everybody would eat well in the mornings. You know, we can't control for everything, though. And so it is a balance. But the time frame of detection, and we'll go through this in a second, is dependent on a few different factors. It is not the same for everybody. If you are an infrequent user of cannabis, you are not going to test positive on an oral fluid test for as long as you will if you were a chronic daily user. If you use a higher THC concentration, more milligrams of THC, that initial level may be quite higher and it may take a little bit longer to come out of your system. They may also test for a little bit longer. But I will argue that if you're using 90% THC, 300 milligrams of THC, whatever it may be, and you have active THC in your mouth, you have to remember, we are testing active THC in their mouth. Where does it go from their mouth? It gets absorbed into their blood. That's where... Or spit out, I guess. But it's in your body. Some policies talk about under the influence, having the presence of an active substance in your body. This is the presence of an active substance in your body. It's not blood, but it's in your actual body. It's in your mouth. It's going somewhere. It's going to be absorbed. Oh, this is what I was looking for before. So this just shows you... This is just one study, but it shows the difference between an occasional user and a chronic user. And you can see they're kind of the same. They have the same curves, except that it's the chronic users that hover around that low level for a lot longer, and the occasional users just fall right off. And so when you hear about people saying, well, I've seen studies where they can test at two or three or test positive. That's just what I hear, because nobody talks about cutoffs. They test positive for 30 hours, 32 hours, 36 hours. That's because they were a chronic heavy user, and I'm going to show you one of the studies just to illustrate that and how much we're actually talking about here. And then this is the one that I was looking for before, where we talk about the very high levels that you see. A bit higher in chronic users, just because they're better able to get in, to be able to sort of take it in. I mean, what we call topography of smoking, how they smoke it is different in some cases. So it can be a little bit different, but generally in and around the same within three hours, we're dropping 95%. So if you look in the middle there, and I realize now that I think it's actually this study here, the Lee et al study 2011. Okay. So if you want the reference to the one I'm going to show you, I forgot to put it on there. My apologies. But the Lee et al study basically looked at how long you're going to test positive on an oral fluid test if you smoke cannabis. All right. So for the people who, what they called chronic heavy users, and these are people that were going into treatment centers, and then they tested their oral fluid. And if you are ever in court, like I am, and you have their, well, you know, there were studies that show that they can test positive for up to, I can't remember now what it was, 30 some odd hours. Okay. Except that wasn't at a two nanogram per mil cutoff. That's the first thing. And the second thing is that even those that did, that was just at limited detection. They used 10 points average of 10.6 joints per day, 10.6 joints per day. Okay. Even in 2011, that's a lot of cannabis. And that's a lot of time. I don't know how one works and uses that much, but okay. Even if you want to say you work in a safety sensitive position and you are that 10.6 joints per day, that's a lot of cannabis and very problematic. So if you want to tell me that it's lasting for longer than 24 hours at two nanogram per mil cutoff, I'm okay with it because I will show you all the studies that speaks to chronic daily users that have prolonged impairment. So that's okay. But that's what we're talking about when we talk about, oh, it can last longer than 24 hours. When we look at the raw data at 10 nanograms per mil, it's about 12 hours. There are some that can test about 14 hours, but again, 10.6 on average. One of them was up to much more than that. I can't now remember what it was, but that is what we're talking about. Again, I'm happy that it tests for longer if you're a chronic heavy user, because you are likely going to be impaired for a whole lot longer than even this is detecting it. But nonetheless, we are still left with the fact that we are testing an active substance in your body, right? In the oral fluid. So that is really what we have done in Canada. Because we are up and we, and again, we don't have federal regulations for the most part. We don't have people telling us like what you can and what you can't do. We don't even have the, you can't test for a metabolite or you have to test for the active or on duty, off duty, et cetera, et cetera. We don't have that. What we have are arbitration and court decisions. And then we have to rely on all of those, and we've had lots of them. I've probably been involved in over a hundred since legalization. And so what I will tell you is what's coming out is the fact that urine is a little hard to defend because you're going to have a lot of people that may test positive who may not be impaired. The occasional user that was off on holiday, decided to have a joint with their friends, may actually test positive for longer than those few days that our studies talk about because maybe they use something higher. Maybe they use an edible which will last longer in the urine than smoked THC. And so, but are they impaired? Probably not. Two, three weeks later, three, five days later, they're probably not impaired. A very, very occasional user. That's what the data tells us. But the heavy user, yes. So you know, where do we draw that line? How do we manipulate the test to be able to get us the information that we need? And it's by cutoff levels. So what does a test tell you and not tell you? It cannot tell you whether a person is impaired. It can tell you the risk of impairment. Were they definitively impaired, you need to do an impairment test. I can't tell you by any drug test, including blood tests. So although in Canada, and you guys as well, have blood levels, we call them per se levels. You can't test above a certain level in the blood of THC from a road, from a driving perspective. But are they actually impaired? There is a risk of impairment, and then there are separate impairment tests that they do by drug recognition experts, right, to determine if they're impaired. These are, you know, cognitive psychomotor testing that they do, and they determine whether they're impaired. In Canada, you can be charged with impaired driving and driving over the per se limits, meaning in your blood there's more THC than there should be, putting you at risk of an injury or an accident, but you also can be impaired. And if you're not impaired, you can still be charged with the over the limit, meaning you've tested over, because you are at risk. And it's that risk that we need to consider from a workplace perspective. And so, policy should not talk about impairment, just to put it out there. Because if you put something that says, you shouldn't come to work impaired, if that's what it says in the policy, then how do you prove that? Because then you get into the, well, how did you know that they were really impaired? Well, there's a risk of impairment. The level was 900. There was a very high risk of impairment. They used very shortly before. But do you know for sure they were impaired? Can you definitively tell me and show me a test that shows me that they were impaired? And the answer is no. And so, fit for duty, good language. Risk of impairment, under the influence, having something in your system. These are all good words. Impairment from a drug perspective, whether it's cocaine, PCP, methamphetamine, et cetera. Unless you were doing a true impairment test, we cannot definitively state that they are impaired. In the interest of time, because we don't have that much time, I just wanna go through that we've had a number of studies that look at medical cannabis. And when I say this, what I mean is people that actually have chronic medical conditions. They've tried a whole bunch of different treatments. They haven't worked. And they are under the care of a healthcare provider at a clinic, having their medical condition managed with very low dose THC, and those are the ones who are in this study. It is not the 73% of Canadians that say, I'm using cannabis for medical purposes, but do not have an authorization, do not have a physician or a nurse practitioner following them. That's not who we're talking about in these particular studies. So with very good oversight, with high CBD, low, low, low THC, one milligram, two milligram, three milligram. Do we see impairment lasting longer than four hours? No. And there's some good studies here. ED is one, Almog is the other. But again, we have to differentiate what medical cannabis means and who the patients are when somebody just comes and says, no, no, no, I have my medical card, I'm using for medical reasons, but what are you using? Because that is important. And how are you using it? The intention of use, et cetera. This is a paper that I was involved in that looked at impairment from medical cannabis. Again, true medical cannabis. Not the 72% of people that say, or 73% that say, I'm using cannabis for medical reasons, but don't actually have anyone that's following them. And they are using whatever they wanna use at a recreational store. And so we talk about putting people into risk categories. Low risk, moderate risk, higher risk. If you work in safety sensitive workplaces, we state that you need to be under the low risk category in order to even be considered from a workplace perspective. But you can take a look at that. I'm not gonna talk about it. But I do wanna talk very quickly about actual impairment testing. There's sort of a rise of all these products that are coming out now. And I have lots of questions about them because I have employers that come to me and say, oh, I heard about this particular impairment test or that particular impairment test. I'm not gonna go through them with names, but if you want to speak to me about it afterwards, I'm here, I'm happy to talk to you about it. We have everything from what the DREs do, kind of in a format that the DRE is a drug recognition expert. Police use those to determine impairment. It's a full, long, long, long assessment that this particular workplace one is a shortened version of it. It's like the SFST, the standardized field sobriety tests with a few extra things that are known to be sensitive to THC. So it takes a person to administer it, but it is tablet based, meaning that it's standardized. So that's one thing. Many of the other ones that were just tablets that a person just does themselves to determine whether or not they are at risk of impairment. Are there signs of impairment that we're seeing on divided attention, reaction time, et cetera? They're good. There's not a lot of studies that have validated many of them with respect to, are they picking up intoxication or risk of impairment that goes beyond, right? So we don't have a lot of that. There are eye ones that look at your eye movements, nystagmus, fluttering, the reaction of your pupils, all of that. And again, all of these are just impairment, not cannabis impairment, but just impairment with any substance. You're gonna see changes on a lot of them from any substance. So at the end of the day, it doesn't really matter what substance. If you're impaired, you're impaired, you're at risk, but there are good ones. But what I will say to you and urge you if you're looking into them, look at the studies, look to see if they're validated and just consider the fact that there are people that are impaired that go beyond the intoxication phase. And are we picking that up with these tests from a risk perspective, from a workplace? We have a good study that talks about the combination of SFST, standardized field sobriety tests with oral fluid to increase accuracy, decrease false positives and false negatives. And it works really well together. So where do I think that this is all going in the workplace? It's gonna be like pieces of the puzzle and using a few of them together because we may have to prove impairment or prove a high risk of impairment and combining things tends to probably be the best. Although we're not using that quite in Canada yet. So, and that leaves us with 10 minutes for questions. So just to put it all together, risk goes beyond acute intoxication, right? The differentiation between impairment, meaning a decreased ability or potential ability or risk of ability, et cetera, to perform a task and a complex task from a safety sensitive or safety critical perspective. Utilizing what we have right now to get the timeframe that you want. And there may not be the same timeframe for even number of companies that you all work for, right? They may have different policies, different standards, different areas that they need to, other than sort of DOT, et cetera. They may have other things that they need to abide by, right? Or they may have philosophies with respect to, yeah, we can't have any risk. We don't want any use at all. So you have to look at that. Hyperbaric, hypobaric, et cetera, also play a role. So there's all of that that we have to take into consideration coming up with that, but it's important to really think about it. Where do you stand? Where do the companies stand? What do they want? Are you gonna differentiate it based on also different positions, which we've seen, right? Safety sensitive, safety critical, this position, this many hours, this position, this many hours, zero tolerance for certain things, less for others. So that's okay too, but it's putting it all together and doing all of that. All right, thank you for your attention. I know I spoke a lot. Any questions, discussion points, anything that anybody wants to hear more about or talk about? Yeah. There is a microphone here, I think, so if anybody wants to come up to the microphone. But if you speak loud enough, I may be able to hear you. I can repeat it as well. I was wondering if there was a component of a surveillance bias, such that people are now given the legal status that we're willing to answer the survey accurately or honestly. Yeah. And there's a book before the legalization statement. I mean, so do you really think that with the driving 15% of people back are driving impaired, do you think that's really always been around that number? And that we're just now recognizing that people are willing to be honest about it? Yeah. Is this really a trend where all of a sudden people are now? So that's a really, really good question. If you didn't hear, I'm just gonna just repeat it. With the survey that I talked about, is there a bias because now it's a legal sentence that people can answer differently? What I will tell you is from a driving perspective and even from a using before workplace perspective, those numbers in Canada have gone down from the beginning, right? And that is because of our, you know, everything we put out there. We tell people you can't drive. We have signs, you know, using cannabis and driving and all of that, all of that that's going on has actually worked. I will also tell you from a workplace perspective that all of the discussions that we've had over the last five, six, seven years, we're actually now starting to see a decreased rate of THC and oral fluid positivity in Canada. Probably because people are realizing, oh, I can't use now within this time, but not everybody realizes it clearly because we still have a lot of positives, but it has gone down. And so yes, I think there's a surveillance bias because I think the percentage of people that have used in the last 12 months, I think people that use cannabis are gonna be more likely to answer the survey, but I think the answers are probably accurate for people that use and it has come down. So, you know, do I think that it's potentially less from a population perspective, but when you take the people that use cannabis, the information that we get about how they use it, when they use it, what they're using, where they're using, et cetera, I do actually think is accurate. Yeah, I know you mentioned 28 days is a kind of a cutoff for impairment, but I've had cases where people, heavy users testing out 90 days, still positive. So how do you deal with that? Because our policy is you must have a negative test before we could clear you to work. Right, so that's urine testing. Yes. All right, so, you know, here's the thing with urine testing and I can argue it on both sides of the coin here. All right, you still have the metabolite of THC excreting from your body. It had to come from somewhere. It is not the inactive metabolite that is stored in the fat cells when they talk about, you know, when they talk about the storage of it, it's actually THC, delta-9-THC and 11-hydroxy-THC, which is an active metabolite of THC. So what is stored in our body is the active drugs. And as they come out of that, they're coming into the blood. And so I can argue, well, if you're still excreting a metabolite, you would have had the active drug there that's now metabolized and excreted, right? It's now inactive and it gets excreted. What does that low level in the blood actually do? We have some of those studies that talk about that. So yes, can it go out beyond the 28 days? Yes, you know, but I can also argue that their likelihood of impairment at 60 days is much, much, much, much lower than that. And the 28 days, again, is the same thing as everything else. At 29 days, that doesn't mean that every single person is unimpaired. Like that's not what that's there. It's just the kind of risk balance, meaning the likelihood of being impaired beyond 28 days is not very high because not every single person is going to be impaired for that long. That makes sense. Good day. You talked earlier about mail-order pharmacies for medical marijuana. Yes. So I'm curious then, is the dosing of medical marijuana actually standardized when it's delivered from the mail-order pharmacy? Good, good, good question. So our medical system in Canada has these Health Canada licensed producers. They are the same producers that are legally able to produce the cannabis for the recreational stores. And in Canada, there is a standardization with respect to quality, oversight, and the labeling of THC and CBD content. So what they're ordering and what it says on that label is different from the studies that show that the labels are inaccurate. Labels are inaccurate in Canada when we're not buying it from that legal place, either recreational or medical. So is there a standard medical dose? No. I can still, with medical authorization, and my medical authorization is only for the number of grams per day, which is problematic, right? I'm allowed to use two grams per day. Let's just say I have medical authorization. I can go to the licensed producer on their website. I can order CBD oil that has zero THC. It's a CBD isolate. And when this one says zero THC, it actually is zero THC. Unlike the other products that we talk about often that are CBD, that are not, there's no oversight, there's no quality control, there's nobody, and when I have a person at a workplace that comes with one that is not labeled the same way our Health Canada ones are, I'll say, yeah, I don't care that it says THC-free. I can't trust that. But from these ones, we can. So I can buy two grams of the CBD isolate with no THC per day, but I can also buy two grams of 90% concentrates from a medical perspective. And so that is why when somebody shows me their medical authorization, I always also look at their invoices because I wanna know what you're purchasing because medical cannabis is not medical cannabis is not medical cannabis. So if you are purchasing CBD isolate or a CBD oil that has less than one milligram or 0.3 milligram per mil, again, I know I trust the quality control of this, then I may think that differently with respect to when you're using it, how you're using it, and when you can use it versus, all my purchases are 80%, 90%, 30%, et cetera, high dose oils, no CBD, all very high THC, that's a very different story. So it's not all the same, but looking at the products that they're buying is what's really important. Here, if someone says they're using CBD, for the most part, it's not regulated. And so you can't trust it. Like you really, we have really good studies to support that. And even in Canada, when someone brings me something that they bought off the internet, not from the legal site, but from all the other sites that are, you know, I don't know, like kind of half legal, half not legal in Canada, I will not, like, you cannot use that. Buy something legally, I don't care if it's more money, if you wanna use it, we need to see what you're using from that perspective. Yeah. Raymond Hicks, what is the effect on impairment of being at high altitude? Ah, yes. Like you work in the Rockies or you're on an airplane. Yeah, so, and that's why we get into the 28 days. So high altitude increase, and this is the same with any kind of substance, drug, medication, et cetera, you have more of an effect, right? As the oxygen levels change, the effect on your brain is different than when we're not at a higher altitude, we're not in a plane, we're not below sea, et cetera. In a mine is the other thing, right? And so all of these may make the difference. And that is why, I mean, that is why most aviation and really consideration for high altitude locations and sites and et cetera, really need to take that into consideration because absolutely there's gonna be a differential. Now, if you live in that area, you do become a bit acclimatized to it. So if you live in a high altitude place, you do become used to that. And so then the effect diminishes, it's different than if you're bringing somebody up from somewhere else and now you're bringing them there. And so you have to kind of consider that as well, but there is definitely an impact, absolutely, with respect to the duration and the nature of impairment, meaning more intense. Great presentation. I know all the talk is about oral fluids, but I guess I have my concerns about it. And you mentioned that it detects the THC that is entered into the mouth. And so if an edible is just quickly swallowed or there's cannabis tablets, I have concerns whether those will even be detected. Because I mean, people, they're smart about how to avoid and I'm sure they'll come up with mouthwashes that help deter that. Yeah, look, so I, you know, and I agree. What I will say is oral fluid is not, you know, everything is kind of plus or minus. So I will tell you that the chance of cheating on a urine test is probably much more prevalent. Even drinking so much water that you're decreasing the quantitative level below the cutoff level, you're gonna see way more of that than people using. And an edible, you're still gonna see it, but it's those, it's the, like the caplets, right? Now, people don't generally use caplets to get high. It gives you a completely different high than when you smoke or you vaporize it, like totally different. And so if they are using it recreationally, most people don't like to use it in that manner. They may use it at night before bed just to calm themselves down and sleep through the night kind of thing. And then would they test positive? No, but you have to weigh that, you know, there is no perfect test. I wish there was. And so will it pick up everybody's use? No, but will it pick up more use than what we're seeing in urine? Yes, we have really good, if you look at the data for the positivity rate in oral fluid and the positivity rate in urine, and we would think urine should be significantly higher because we're detecting it for so much longer. So it doesn't intuitively make sense that the oral fluid positivity rates are significantly higher for THC, but they are. And that's because we are not diluting it out. So it's sort of, you know, you got to kind of balance it out, but that's what we see. Good morning. How do you manage law enforcement officers and firefighters? Sorry, say that again. How do you manage, they're expected to work 24 seven. Oh. How do you manage them? Yeah. How do we manage? So it's a good question. We, our, we have many industries and our police forces are one of them where they are just told to show up fit for work and they don't do any kind of testing. And I know that sounds really hard to believe for people that live in the States where you do way more testing than we do. We are limited in the testing that we do. We are very limited from a random testing perspective outside of DOT and a few places that have shown that they have a significant problem and they kind of can do random testing. It's just not commonplace. And so testing is not even commonplace. Like even in our, even in parts of our armed forces and aviation, they just don't necessarily do testing. They have policies, but they don't necessarily do testing. So managing it is education and crossing our fingers that they actually listen, which they don't. But that, I mean, it's crazy. So how we do it and how you should do it may be two totally different things. Hi. Thanks, Melissa. That was great. So if you can, in Canada, get a zero THC in a CBD product from a licensed producer, what's happening with safety sensitive in those cases when someone has an authorization and they have a safety sensitive job, but they can get a 0% THC? Yeah, so it's a good question. So the pure CBD isolate, so I say the word isolate because that means that we've taken every other cannabinoid, terpene, everything out of the equation. We are only left with CBD with nothing else at all. And again, you can only depend on that if you are able to depend on the testing of it. Like, you know for sure that that's what the product is. So in Canada, when we have that, we have, and again, we do, and I think this was talked about yesterday if you went to the MRO talk about independent or evaluations that are unique to each individual. Basically, anyone with medical cannabis you need to be taking a look at as opposed to a carte blanche sort of policy statement about medical cannabis here and in Canada. And so for that, I have returned people to work with CBD because there was very, very, very good evidence that after the first couple of weeks, if there are no adverse effects, the same thing with other medication, that there are no impairments with respect to CBD. We have really good new studies that look specifically at that. And it really is the THC, the other cannabinoids and the terpenes in it that have much more of a role with respect to impairment. But, you know, they should not be testing positive at all. And so now you do testing and they have a THC in their system, I don't care if it's urine or oral fluid, then they're clearly not only using their CBD, but yeah. Yeah, thank you. Yeah, and topicals, just if you get asked, topicals actually do not get absorbed through the skin. There's a difference between a topical and a patch that is designed to carry the cannabinoids into the bloodstream. But if you take a cream, like, you know, my mother has arthritis of her knee and uses a cannabis cream, who would know that my, you know, 70 some odd mother would be using cannabis. But she does, and she rubs it on her knee. And it actually does help locally from an inflammatory perspective, but it does not get absorbed through the blood unless you have open skin. So people with psoriasis, people with cuts, people with eczema, whatever, where their skin breakdown, it can get absorbed, you can test positive out, or if you use your hands and put your hands in your mouth, your nose, your eyes, you're gonna test positive because you're gonna get THC in your system. But outside of that, it doesn't get absorbed through the skin. So generally speaking, they're probably okay with that little caveat of skin that's not broken down. Any other questions? All right, thank you everybody for your time. Thank you.

Melissa Snyder-Adler

addiction medicine physician

cannabis use

workplace post-legalization

intoxication vs impairment

oral fluid testing

THC cutoff levels

drug testing policies

medical marijuana dosing

workplace drug policies