In this episode, we explore the evolving landscape of cannabis use in Canada with Dr. Daniel Myran, a family doctor and researcher specializing in the societal impact of substance use. We discuss the potential health impacts of cannabis, including its link to psychosis, the rise of cannabis hyperemesis syndrome, and the dangers of high-potency products. Dr. Myran also shares his insights on the challenges of communicating health risks, the importance of social accountability in research, and the emerging field of psychedelic research.
Please note, this podcast was recorded before the holidays, which is why we refer to holiday dinners in one of our questions.
Our guest:
Dr. Daniel Myran is a public health and family medicine physician and researcher. He holds the Canada Research Chair in Social Accountability at the University of Ottawa, and is an ICES Adjunct Scientist, Investigator at the Bruyère Health Research Institute, and a Clinician Investigator at The Ottawa Hospital. His program of research involves using health administrative data to examine the burden and societal impact of mental health conditions and substance use. Dr. Myran’s primary focus is examining the health impacts of changes in alcohol/cannabis and drug policies and their influence on health inequities. As a secondary area of interest, he uses big data to examine the health of physicians and their practice patterns.
Read the research from Dr. Myran:
Read the Op‐Ed: There are good reasons to be anxious about growing cannabis use in Canada - The Globe and Mail
2. Emergency department visits involving hallucinogen use and risk of schizophrenia spectrum disorder
5. Unintentional pediatric poisonings before and during the COVID-19 pandemic: a population-based study
Misty Pratt
It’s been six years since cannabis was legalized in Canada, and our country was one of the first in the world to provide legal and regulated access to cannabis for non-medical purposes. Many applauded the move; others worried that we were embarking on a dangerous social experiment. Even before legalization, the rate of cannabis use more than doubled from 1985 to 2017, from 6% to 15%. Statistics Canada reports that cannabis use has also increased since legalization, but that the pandemic may be the culprit. As routines changed and stress rose, people may have turned to recreational drugs for relief. Time will tell whether these rates continue to rise, and what it means for our health and well-being. To help us navigate the evolving research on cannabis and weed out the misinformation, we’re joined by ICES scientist Dr. Daniel Myran, a family doctor who studies the societal impact of substance use.
Daniel Myran
I think there are a couple of major questions that we have about cannabis and its health impacts, and I think probably the largest one—and it’s actually a well-researched area—is whether or not cannabis use can cause psychosis in schizophrenia.
Misty
Welcome to In our VoICES, the podcast that takes you beyond the data to meet the people and hear the stories that help shape health and healthcare for all of us. I'm your host, Misty Pratt, and I'm one of the people behind the data who make the difference at ICE, a health research data and analytics institute based in Ontario, Canada. ICES staff, scientists and partners are on a mission to make health care better and people healthier. In this podcast, we share our stories in our voices. A note that the opinions expressed in this podcast don't necessarily reflect those of ICES.
Dr Daniel Myran, welcome to In our VoICES.
Daniel
Thanks for having me on the podcast.
Misty
Thank you for being here. I want to start with your Canada Research Chair in social accountability at the University of Ottawa. Can you tell us what social accountability means?
Daniel
So broadly, social accountability is the idea that the research we do should both involve the communities impacted by it and ensure that it’s relevant to the needs, health concerns, and, essentially, the problems affecting those communities. I interpret that in two ways. First, I view substance use as an issue that is having a significant health impact on Canadians. Closer to home, here in Ontario, it’s also a very large issue and an area of research where we urgently need more evidence on—what are the impacts of substance use, and what policies can be put in place to mitigate some of those harms and disparities? The second piece of social accountability research is: how do you ensure that the research you’re doing involves people who are relevant to it? That includes the communities impacted and the decision-makers who will use your research. Both these streams move together to ensure, hopefully, that the research is impactful and relevant to people.
Misty
So if we’re talking about recreational drug use, how would we involve that population in the research?
Daniel
I think it's really interesting to think about how you involve people. And I find that the voices and the perspectives that they bring are really helpful for understanding a lot of stuff that, even as a clinician, you may not be aware of, of the details. So, interacting with people, you understand what types of products they're attracted to, how they're using products. And those actually give you a lot of insight into what is popular and what may be associated with harm. And then also, as part of the social accountability lens, it involves impacted communities and individuals, but also the decision makers and regulators. So, a lot of the work is about saying, we're doing research on this particular policy and speaking to people at Health Canada or speaking to people at the Ministry of Health and saying, what do you need to know about? What are the things that would help you in your decision making or regulatory choices? And that often helps us pick topics that—it doesn't change the direction of what we look at, but it helps us decide, this is something that's really important to them and they're thinking about making a decision on. Let's do research in this area to help bring evidence to the gap that's there.
Misty
So you're kind of letting people in the community decide a little bit what is important to them.
Daniel
Because we're the data experts. We know how to work the data. We know what the data has. We know its challenges. We know its strengths. And we don't always know what someone is thinking about making a change on. Are they thinking about changing the types of products that can be on the market? Are they interested more in marketing regulations? Are they interested in poisonings in young children? Are they interested in episodes of psychosis in young adults? And all of those questions can help you say, what's a priority? What do we need evidence for?
Misty
What inspired you to conduct research in this area?
Daniel
Much of it is related to timing of, when I finish med school, when I finish up my training, and it just so happens that I finish up my Master's of Public Health as part of my Public Health Training right as legalization is coming out. And I actually started in alcohol control policy. My Master's of Public Health was looking at evaluating what happened to emergency room visits involving alcohol after the Government of Ontario introduced alcohol sales in grocery stores. And I used health administrative data to say, did emergency room visits change more in regions that got a grocery store that began to sell alcohol than those that didn't? And it felt like a very natural next step to start looking at cannabis legalization and cannabis policy. Because actually, many of the features that you have evidence for from alcohol, about what impacts how much alcohol is used, what causes alcohol harms to be higher or lower, have many parallels for cannabis. You end up saying, we think that price will be really important. We think that marketing will be important. We think that the availability of stores will be important, but we don't know, because no one's done this for cannabis yet. Let's take that evidence base and let's apply it to legalization as it unfolds, to evaluate it.
Misty
And how did you feel when cannabis was legalized?
Daniel
So, I actually wrote an op-ed at the start, right around the time that legalization was happening, cautioning that there is a lot of nuance to legalization. We often say that this is often conceived as a binary, yes-no event—you legalize cannabis or you don’t legalize cannabis. But there are many different variations in how it can be legalized and in the implementation. And those have actually happened across the country. If you look at the different provinces, there are many different forms that it’s taken. But at the onset of legalization, I was pro-the-decriminalization of cannabis and removing the criminal justice harms, which are broad, completely inequitably distributed in society, falling mostly on Black and Indigenous Canadians.
And there was a major public health harm that happens. And I was very pro removing those criminal records, those criminal challenges, but I was very concerned that we would end up with a very commercialized cannabis industry. And what I mean by that is a system where the sale of cannabis became very oriented towards making large amounts of money for corporations. And that you would move from the idea of saying, we're legalizing this, but we want to ensure that as few young people are using it as possible, and that there isn’t a lot of marketing, and that the products that are on the market are aimed towards being less harmful products, to instead the focus being on, again, making a lot of money, attracting users of cannabis, and growing a market. And I think that as we have ended up—as the market has evolved, as our legalization process has evolved and matured—that we have ended up much towards that commercial side than public health individuals would have wanted. And I think that is not optimal for people's health.
Misty
And with commercialization comes probably a greater use of cannabis. And so a lot of people talk these days about the health benefits that might be beneficial for sleep or chronic pain or for cancer patients as well. Cannabis has a very long history of human use, and there are a lot of health claims made about the benefits of cannabis. Are they backed by science?
Daniel
I think the way cannabis rolled out in Canada is really interesting because we, of course, had medical cannabis legalization and then a decent increase in access to medical cannabis before we legalized cannabis for non-medical or recreational purposes. And as part of the lead-up to non-medical legalization, there was an increasing idea that cannabis can act as a medicine and that it can have benefits for a variety of conditions. It's not my role. It's never my job to say you have individually not benefited from this. So, for people who say that cannabis is really wonderful for my sleep, or I find that my osteoarthritis is much better managed, or I feel less anxious when I take it, I'm happy that they're feeling that they're benefiting from it.
The evidence base for it as medicine is not fantastic. When you look at these larger views of what happens with cannabis for a variety of conditions, there isn't strong evidence as a sleep aid, there is not strong evidence for it being particularly effective for pain. So, it ends up being a second or third-line agent that you would try after you've tried other things first, and for which people get a very small reduction in pain if it does work for them, and have an almost equal risk of side effects like being drowsy or feeling not enjoying the experience of taking it. There's a small number of very specific things for which it's ended up having reasonable evidence, for rare pediatric seizure disorders, for muscle spasticity in people who have multiple sclerosis. But at the end of the day, I don't think that the body of evidence has come out saying that this is supporting a lot of the claims that have been made for it as a silver bullet drug or therapeutic that would improve a lot of things.
Misty
Do you think we'll ever get to the point where the evidence is more definitive for certain conditions?
Daniel
So, this is absolutely not my area of expertise. I think that one of the challenges that people who are really interested in the therapeutic uses of it face is that after non-medical legalization in Canada, many people who are interested in using it for medical reasons switched over to acquiring it from the non-medical market because it became easier, potentially cheaper, and there have been—again, my understanding is that there have been— a lot more hurdles for getting drug trials out of the way, and maybe less of an interest in running drug trials once it’s now, again, if you think about it, if you have a very large non-medical market, and people can access it fairly easily, there isn’t always the need to run a drug trial, which can be expensive and time-consuming. So, I think there have been challenges building that evidence base that people are looking for here. I don’t know what the long-term data will show. I think for many of the promised health benefits, like pain and sleep, I’m not convinced that you need that much more data. Kind of the evidence is in, and I don’t think that running more trials is going to tell us suddenly that this is much better for pain relief than we currently see does.
Misty
And what are some of the key health impacts of cannabis use that are currently under-researched?
Daniel
I think there’s a couple of major questions that we have about cannabis and its health impacts, and I think probably the largest one—and it’s actually a well-researched area—is whether or not cannabis use can cause psychosis and schizophrenia. And there have been many, many studies, and interest in this dates back, actually, hundreds of years.
You have case reports in old, stuffy British medical journals about people who develop psychosis or schizophrenia after using cannabis. So, this is not a new idea, but there has been an ongoing debate in the literature about whether it’s a causal association. So, essentially, are there individuals who, after using cannabis, will develop schizophrenia, who otherwise would not have? If they had not used cannabis, they never would have developed schizophrenia. And it’s not a settled question. People are starting to use pretty innovative, new approaches to get to the bottom of the question. And I think that there is—at least to my mind—there’s pretty compelling evidence that some of the association is causal, that there are some individuals who probably develop schizophrenia from using cannabis who wouldn’t have otherwise. But I also think that some of the association that we see in the epidemiological literature is related to confounding—so, other factors that both increase the risk of schizophrenia and make people more likely to use cannabis.
Misty
So confounding meaning, if somebody, perhaps was already feeling anxious or having other mental health symptoms, maybe they're using cannabis to treat those symptoms.
Daniel
So, there’s three ideas, right? You look at this epi association between cannabis use and schizophrenia. The first idea is that there’s a causal component, right? This is really causing schizophrenia in some individuals. The second idea is confounding, and that’s thought to be from either shared genetic factors. So, for example, you have a series of genes that predispose you towards schizophrenia, and they also happen to make you more likely to use cannabis, or an environmental or lifestyle risk factor. So, maybe you had a series of adverse childhood experiences, and those, we know, increase your risk of having schizophrenia later on, and probably increase your risk of heavy cannabis use later in life. And then the third one that you were highlighting is what’s called reverse causation. So, the idea is that you have someone who has early symptoms of psychosis or schizophrenia—maybe they’re becoming slightly paranoid, they’re having some hallucinations, and they’re quite distressed or anxious about it, because people would be—and they’ve heard that cannabis might be good for anxiety, so they start medicating the symptoms, or trying to medicate the symptoms of it, with cannabis. So, even though it seems like there will be a strong association between the cannabis use and schizophrenia, it wasn’t causal. It was actually that person just medicating something that was already starting to unfold or happen.
Misty
Yeah, and I can see how that would be really hard to tease apart.
Daniel
And there have been people doing clever studies, and again, clever designs that I don’t do. So, you have really interesting studies where you have everyone’s genetic sequenced, right? And you figure it—so, you have everyone’s genome, and everything’s been sequenced. The genes that are associated with schizophrenia, and you can see the genes associated with cannabis use, and then you have additional data about people’s cannabis use and who develops schizophrenia. And many of those studies are continuing to show that even adjusting for genetics, you see this association persists. And there’s been other studies where people have said, let’s look at the timing of when people use cannabis and when symptoms of psychosis began. And again, you see that there is a pretty strong association between cannabis use and psychosis, but not a very good association between psychosis and cannabis use, so maybe less evidence for the idea of self-medication.
Misty
So other than the genetic piece, are there characteristics that of certain populations that would perhaps put them at a greater risk?
Daniel
For both cannabis use and schizophrenia, one of the strongest predictors for psychosis and schizophrenia is family history, because it is very genetically related. The other factors seem to be that younger age and male sex are both pretty strong risk factors, both for heavy cannabis use and for schizophrenia.
Misty
And you may not know the answer to this, but why would it be males? Why is there something there, genetic-wise or biological?
Daniel
Again, we're stretching my expertise, but my understanding of what is commonly thought of is that because of sex differences in how the brain matures and how neural connectivity stops being as plastic or changeable, the male brain is more vulnerable. Again, this is the hypothesis: a male brain is more vulnerable to adverse changes from cannabis use because it has less cortical maturity early on. So, during the window when you're going to be exposed to a heavy amount of cannabis use (or potentially exposed), female brains are often more matured and less susceptible to it, while male brains are still in a vulnerable window or period.
I think another area that our research has looked at but hasn't been able to be studied in the same way, is looking at a condition called cannabis hyperemesis syndrome. This is a disorder where people who use cannabis daily or almost every day, particularly those using higher strength or higher THC products, develop very severe nausea and vomiting. Many of these individuals actually end up in the emergency room because they don't understand what's happening. They come in with very bad stomach pain, and one of the hallmarks is that their symptoms actually improve with hot water, like they might be taking an hour-long hot shower to try and get relief from their symptoms.
Historically, this condition has been very rare. It was more of a case report-type thing 20 years ago. However, what we saw in our study is that it's really increased quite rapidly over time in Ontario. There has been a very large increase in the number of people coming in with this condition, and it seems to accelerate after the legal market in Ontario commercialized. In early 2020, the market shifted from only having a very small number of stores and restrictions on the types of products that could be sold (like dried cannabis flower) to a market where vapes with THC and concentrates (which is THC in very high concentrations due to processing) became available.
You see a pretty large immediate jump in people coming in with cannabis hyperemesis, and it’s all quite consistent with data showing the growing number of people using cannabis daily or near daily in Canada, along with the rising THC potency of products. To put this into context, the cannabis people were familiar with in the 1970s had 1-2% THC in dried flower. This rose to around 4% by the early 1990s, and by 2010, it was around 10-12%. The average THC content of dried flower you would buy in a store across the country right now is 25%.
So, this is a very different substance from what people are used to or think of if they had experiences with it in the 70s or even the early 2000s. In the literature regarding the association between cannabis and addiction, psychosis, and other adverse mental health harms, ultra-high potency cannabis is defined as anything with 10% or more THC. So, the cannabis available on the market today is much more concentrated than what people have evidence for or what has been studied in the past. It really does seem to have come together for some of the conditions we’re worried about, like cannabis hyperemesis or cannabis-induced psychosis.
Misty
Yeah, because I've seen some of the products at 10% be marketed as low THC.
Daniel
10% like if 20 years ago, that would have been an unthinkable product, and it would have in the literature, would have looked at that as something as like a very high potency, high risk product. So again, the stuff that has been created and is on the market, is just very, very different, and we're actually now up against some of the theoretical limits of what THC content you can get into dried flower. And one of the trends that seems to be happening is that you're now moving into pre-rolled cannabis products, which has dried flower, but then it has processed concentrates that are dried up and sprinkled in, to move past that limit of what you can put in.
And I think that this is one of the real challenges with commercialization, that we have ended up with products that are becoming potentially more and more risky. And there's an irony that I think the risks of some of the cannabis products that are on the market right now are higher than they've ever been at an exact time that society's conception of the risk of cannabis is at an all-time low. And again, people—there was like reefer madness in the 70s, where cannabis was not actually that risky. And now we're saying that cannabis is, you know, innocuous, or perhaps a medicine, and it's actually evolved to be quite distinct, and perhaps now truly is a much more risky substance.
Misty
We’re coming up to the holidays, when many people will be kicking back with a cannabis gummy or their favorite alcoholic drink. How receptive are people to hearing about health risks?
Daniel
I think it really depends on the health risk and on the person. One of the interesting policy pieces has been the health warnings that are put on cannabis products in this country. And Health Canada actually is going through a series of revising them. They've revised them before. They're revising them again right now. And a lot of the challenges that they've had is that some of the health warnings that they want to put on cannabis are not always believed by people who are using cannabis.
I think that broadly, we've done studies about treatment for cannabis use disorders during pregnancy and how that changed after legalization, and whether or not requiring treatment for cannabis use during pregnancy was associated with problems with the babies born to people who used cannabis. And I think generally, people find that sort of evidence fairly believable, with lots of people saying, yeah, this is probably not a great thing to be using during pregnancy. But again, there's a subset of people who really, they're not as receptive to that messaging. There's a lot of individuals who are interested in using cannabis during pregnancy for control of morning sickness.
And again, these are very hard and challenging conversations, and the evidence is, we don't have causal evidence saying that if you use cannabis during pregnancy that it increases the risk of babies being smaller, or babies being diagnosed with autism spectrum disorder or ADHD, when they're five or six. There's concerning associations, but it's hard to communicate the degree of certainty that people are looking for. And if you think about tobacco, when we communicate about tobacco, for example, there's no problem saying tobacco causes lung cancer, tobacco increases your risk of heart disease, because the evidence base for cannabis is not as advanced as it is for tobacco. It often makes the communication more challenging.
Misty
Are there any other health risks that your research has found?
Daniel
I talked about schizophrenia and psychosis as one of the areas that we were looking at and focusing on. The other big areas that we've monitored and been interested in are poisonings in young children. So we've done studies looking at whether kids under the age of nine have had increases in hospitalizations or emergency room visits from cannabis. And what we found was that there were very large increases in the country.
We did a study where we compared poisoning hospitalizations in Ontario, Alberta, and British Columbia, all of which allowed legal cannabis edibles to come to market, and compared them to changes in Quebec, who didn't allow edibles to come to market because they were concerned that they would be very appealing to young children. And we found that after legalization, and when the edibles came out, you have a seven-fold increase in hospitalizations. They're seven times higher in kids age zero to nine.
And in Quebec, they only go up by two-fold, or two times, so very large increases in child poisonings. They're, fortunately, quite rare. When we did a study spanning, I think it was seven years, there were just over 500 hospitalizations in children for cannabis poisonings. I'm not a pediatric toxicologist, but colleagues who I worked with on the study are. They see young children who go to the ICU because they have stopped breathing from a cannabis ingestion. And if they had not been ventilated in the ICU, they would have died. So they can be quite severe.
And what's interesting is that the THC limit that we currently have in legal edibles in Canada is right at the point of toxicity for young children. So you have a single gummy or piece of candy is not allowed to have more than 10 milligrams of THC in it. And it just so happens that if a young child eats two or three pieces of those, that is enough for them to potentially need hospitalization. So young kids are very, very susceptible to these. And it's been, I think, a concerning, a concerning thing to see from the toxicity. And again, when you see kids with these hospitalizations, it's probably just the tip of the problem. So for every kid who shows up in emerge, who's been hospitalized for a poisoning, there's potentially more kids who had a smaller ingestion that didn't show up.
Misty
So what would you say to parents about that?
Daniel
I think that there has been better communication about this, but cannabis needs to be treated like a medicine and a toxic medicine. So, the places where people might have opioids or benzodiazepines or heart medications, all of which can be very dangerous for kids to ingest, cannabis needs to be treated in the same way. So, ideally in a locked place, part of the problem that is likely occurring with cannabis is that these products are incredibly appealing, that once they are out of their packaging, they are indistinguishable from candy and chocolate, because they are candy and chocolate. And again, I was talking at the start of the podcast about commercialization, and it is my honest view that there is absolutely no reason to have the legal sale of highly appealing candies that contain cannabis, that adult consumers have a wide variety of other ways that they can get cannabis. And this is just not a product that needs to exist, and I agree it exists on the remaining illicit market, and I think that there's societal problems of pursuing, of just saying that any product that exists for sale illegally should also be offered for sale legally.
Misty
How can data like that held at ICES inform better policy and education about cannabis use?
Daniel
I think what's so unique about ICES data is that it's at the population level. So we're really capturing healthcare visits for everyone in Ontario, and that it's linked. So that you can follow people over time, you can understand their healthcare history at a point in time, and then you can follow them forwards. And I'll give you two examples. So one, there's been studies before about whether people who have an episode of cannabis-induced psychosis. So this is someone who shows up in emerge, they've consumed cannabis, then they're having hallucinations or paranoia, and the treating team thinks that it's linked to the cannabis use.
And there have been very small studies before about that, but because we have the huge ICES linked data, we can do studies where we look at that association, and we look at it for men and women and for people of different ages. And, for example, one of the things that we found was that someone who shows up in the emergency room for cannabis-induced psychosis, who has never received healthcare before for schizophrenia, within the next three years, 26% of them will be diagnosed with schizophrenia. And amongst men aged 15 to 24, it's 40% who will be diagnosed with schizophrenia. Almost half. And to me, it identifies a group who absolutely needs very close monitoring, further intervention, and the health system should be thinking about it. These are, we have specialized first episode psychosis programs where people who come into emerge with psychosis are followed up and treated. And I think this is a group of individuals who should be urgently sent into those first episode psychosis programs.
Misty
What are you working on now?
Daniel
We're doing a couple of different projects right now. One of the areas that I'm quite interested in is related to psychedelics, or hallucinogens. There's been a lot of interest in psychedelics, and particularly arising from trials of psychedelic-assisted therapy, where people with a couple of different mental health conditions, including substance use disorders, post-traumatic stress disorder, treatment-resistant depression, receive a psychedelic like magic mushrooms or psilocybin combined with therapy or counselling, and there's some data showing that it may be effective in those conditions. And along with those trials, there has just been this absolute surge of public interest in hallucinogens and psychedelics.
And we don't have wonderful data in Canada, but data from the US is showing that this has doubled or tripled amongst adults in the last eight years. I think the latest estimate was that 10% of people aged 18 to 30 in the US had used a hallucinogen in the past year. So, a very large segment of the population is now using these, and we have almost no data on their health effects. As many gaps as there are for cannabis, the gaps for hallucinogens are much, much higher. So, I think we're interested in understanding what are some of the associations between hallucinogen use and health harms. And then, from a regulatory perspective and from a policy perspective, how is use in visits related to hallucinogens changing over time in the country? And there's many similarities between hallucinogens and what's happened with cannabis, and there's many distinctions. And I think it's interesting to bring this data to help inform some of the policy debates that are going on about whether or not this should be legalized for recreational or non-medical use, and inform some of the clinical decisions that are happening about whether this is as safe as some of the trials are saying hallucinogen or psychedelic uses.
Misty
Do you see legalization coming for psychedelics?
Daniel
I think that, to me, when I think about this, is that right now, again, it feels like our societal conversation is conflating these two: that we're saying, "Oh, medical uses of psychedelics and recreational use are often discussed as a similar thing." It's, "We should make this legal and available because it has medical purposes." And these are conversations that should absolutely not be conflated. I think that there is an urgent need to generate high-quality evidence about the medical uses of these and for medical use of this to occur in a way that's accessible for people who would benefit from it, in a way that's regulated and prescribed, because, again, the populations that we're talking about who may benefit from this generally have quite severe pre-existing mental health conditions, and you want a trained healthcare provider with experience to be there, helping to decide who would benefit, helping to monitor for adverse effects.
And then the other piece where we say, "There's an interest in legalizing this for recreational or non-medical use," that's a very important and reasonable societal conversation, but it should not be: "We're doing this for medical reasons. We're doing this to benefit people's mental health or well-being." It should be a conversation about, "We're doing this because we believe, as a value of people's civil liberties, that this should be a drug that can be consumed by people who want to." And I worry that those two debates are often lumped together, and that we're conflating the two ideas and may end up with, and I don't think you end up with good drug policy for either side if you mix those together.
Misty
Yeah, that makes a lot of sense. Well, we have to leave it there for now, but I just want to thank you so much for being here. This was really informative and fascinating.
...
To learn more about Dr Myran's research. Visit our website at ices.on.ca and navigate to the Publications page. There you can search by topic or by scientist. We'll also link to all the research that Dr Myran referenced in our show notes. Thanks for joining me for this episode of in our voices. Please be sure to follow and rate us on your favorite podcast app. If you have feedback or questions about anything you've heard on in our voices, please email us at communications@ices.on.ca, and we'll be sure to get back to you. We might even share your feedback on a future episode. I'm Misty Pratt in wishing you strong data and good health.