Spotlight Series: Dr. Carolina Landolt of SummerTree Medical Clinic
Summertree is the only cannabis clinic in Canada operated by a Rheumatologist. Dr. Landolt works with patients to determine whether cannabis is a suitable treatment option and she helps her patients find Licensed Producers or to apply to cultivate their own medicine and provides education on using medical cannabis safely. Her services don't cost patients extra money because they are covered completely by OHIP - the Ontario Health Insurance Plan.
She sat down to chat with us about treating patients with cannabis.
I read on your website about the first patient you had who helped you understand how medical cannabis had helped alleviate some her suffering. Clearly, that experience and similar cases that followed impacted you and your interest in cannabis. Were you aware of the therapeutic benefits prior to that first patient?
Before opening Summertree, I ran a lupus practice for over 8 years. My patients were quite young and would often tell me about using cannabis to manage their fatigue or sleep. I honestly didn’t see their cannabis use as a problem but I also never considered it as part of their lupus treatment. I viewed these conversations as an indication that we had an open and honest patient-doctor relationship where my patients were comfortable in disclosing information that might be seen negatively by the medical community.
Are there particular rheumatic conditions where cannabinoids have promise?
Certainly, cannabinoids do hold therapeutic promise for many conditions. Unfortunately, comprehensive research has not been possible and this has obviously limited our understanding of specific conditions where cannabinoids may be beneficial. Currently, cannabinoids are useful in improving symptoms such as chronic pain or insomnia in situations where standard medications have proven ineffective. In our clinic, we have been surprised and gratified to see success in a large number of patients suffering from fibromyalgia. Fibromyalgia is certainly a life-altering condition where current treatments are not particularly effective. At this point in my practice, I would certainly recommend a trial of cannabinoids for patients struggling with this condition.
Does the type of cannabinoid and method of delivery seem to make a difference in its efficacy and safety?
The choice of consumption method really comes down to the needs of the patient - how quickly do they need their medication to work, how long do they need it to last. For someone who has daily pain, using oils might be best as it allows for a stable, more long-lasting effect. On the other hand, if someone has migraines that happen unpredictably, they may opt for vaporizing as it works more quickly. There’s not a superior method, it’s what’s best for a particular individual.
What are the main risks of treating chronic pain with cannabinoids? How do the risks compare with the risks of other drugs used to treat long-term pain?
Ideally, everyone would live their lives free of medications. When you’re using something medically, it immediately means that things aren’t optimal. Every drug is a compromise because the ideal is being healthy without the need for medication. Any substance people take is to manage their situation and its possible outcomes to the best extent they can.
Have you seen any cases where patients had adverse reactions? How do you recommend a cannabis naïve patient approach the treatment for optimal results?
What we’ve seen most often are patients who’ve run into problems because they have consumed cannabis intended for a recreational market. Seeking a medical solution through a recreational avenue is not ideal. The way people approach consumption in a rec market is quite different to a medical dosing strategy where you start with low doses and work up until you find a reasonably effective dose. In this way, if people run into side effects, which can happen with any medication, it’s easier to advise patients on a safe course of action.
Who is a good candidate for medical cannabis?
Good candidates in our practice are people who continue to have symptoms such as pain, sleeplessness or headaches, despite ongoing standard of care or who cannot take traditional medications due to side effects.
What are some of the challenges, if any, that you’ve faced since starting to work with medical cannabis as a treatment option?
The predominant challenge at this time is access to cannabis knowledgeable doctors. We get daily calls from people who are wondering how they might get referred to our clinic, as many of their primary care physicians do not see cannabis as a viable medical option. A challenge for our clinic is that the responsibility of educating cannabis naive patients and assisting them in navigating the bureaucracy associated with cannabis access falls squarely on our us. With other medications, we would rely on pharmacists to also provide patient education at the time the prescription is filled. This additional layer of expertise is missing in the realm of medical cannabis and hopefully, this gap will be addressed as this field develops.
What suggestions do you have for patients who are having a hard time getting their GP to refer them to your clinic? Do patients whose doctors are uncomfortable with cannabis have options?
The major difficulty here is that this is a very charged issue for physicians. Doctors want to do right by their patients, but they are unfamiliar with potential benefits associated with medical cannabis. Many doctors aren’t just sceptical of medical cannabis as an option, they are also sceptical of cannabis-specific clinics and the level of care their patients can expect. We try to exceed expectations by being measured in our approach to cannabis prescribing, providing a wealth of education, and providing frequent and ongoing care - we feel our patients are our best representatives. When patients report improvements in symptoms or they are able to decrease or discontinue other medications such as opioids, this is both significant and reassuring to their family doctor. Having said that, there are many physicians who will simply not refer patients to a cannabis clinic and for patients who find themselves in this situation, this can be extremely frustrating and disappointing. The only option individuals have is to seek out a cannabis-specific clinic with family doctors where patients can self-refer. This limitation can very much limit access, particularly in remote or small communities.
What can a new Summertree Medical Clinic patient expect on his or her first visit?
The first visit at Summertree starts with a review of your full medical history. Once we have all the details, we’ll discuss your treatment goals together and decide where cannabis might fit into your routine. If it seems like a good fit for you, we then help you register with a licensed producer - we’ll work with any producer on Health Canada’s list of licensed grows. We usually suggest a producer for you based on the availability of strains that have been recommended for your treatment goals. Follow up visits will occur as required.
What advice would you have for someone who is considering medical cannabis as a treatment option? Where should they go to find more information?
What people need to remember is that with any health issue, you need to be your own medical advocate. It’s important to ask questions and have the conversation. If your doctor can’t answer these questions, then it might make sense to see a physician with more experience in this area. This discussion should be free of bias as with any other medical conversations - what are the pros, cons, things to consider in regards to your particular situation. The responsibility of asking the question lies with you, the patient, and the responsibility of answering the question lies with a physician with expertise.
What advice would you offer other Physicians interested in prescribing or learning more about the therapeutic value of medical cannabis?
There is some literature that doctors may seek out in medical journals, and stay tuned to the future studies currently being conducted. Even in large professional conferences, there will be more and more discussions about medical cannabis. Things don’t usually go from 0 to 100 with doctors, but this issue is starting to bubble up. Approaching physicians who are currently prescribing cannabis to discuss is a great way to gain knowledge. Patients who have been successful are the best advocates - good outcomes for patients are the type of evidence that doctors can get behind. If you’re seeing positive trends in your patients, that becomes very instructive. One of the problems with cannabis is that most of the examples to date are those who acknowledge using cannabis, which are usually recreational users who are not representative of a full set of patient demographics. Doctors don’t usually have positive medical cannabis user experiences.