Use of Medical Marijuana for Complex Symptom Management in a Pediatric Patient with Epidermolysis Bullosa

Background: Pain and nausea associated with chronic disease are often difficult to manage. Myriad studies have shown that inadequate symptom management leads to poor quality of life and function. This problem is magnified in pediatric patients, with its impact on normal development and family life. Medical marijuana demonstrates efficacy in managing pain and nausea in adults. However, there is a significant research gap regarding its use in pediatric symptom management. Case Description: Patient is a 13-year-old male with recessive dystrophic epidermolysis bullosa, 10 months post bone marrow transplant, admitted for worsening pain and nausea. He was unable to tolerate PO requiring total parenteral nutrition (TPN) and his pain remained inadequately controlled despite greater than 1500 mg oral morphine equivalent daily. He was managed by an interdisciplinary team (pediatrics, palliative care, nutrition, psychiatry, social work, nursing, PT/OT, child life), with regular meetings. On day 29 of admission, medical marijuana was started with a 20:1 THC to CBD formulation. Within three days, nausea and pain significantly improved, shown by a >50% decrease in PRN medications for both. He also started eating a regular diet. A 1:20 THC to CBD formulation was added to treat muscle spasms, which led to a significant decrease in antispasmodic medication and improvement in his ability to work with PT. His mood also steadily improved. On day 57 of admission, he was discharged home with fentanyl 100 mcg/hr patch, methadone 25 mg PO q 8 hours, oxycodone 20 mg PO q 2 hours PRN (minimal doses per day), medical marijuana PO q 4 hours PRN, and tolerating a regular diet with no TPN or central line. Conclusion: Medical marijuana is a promising therapeutic option for pain and nausea management in adult patients. This case demonstrates its potential in chronic complex symptom management in pediatric patients as well.