This chapter (Cases 26–50) showcases progressively complex scenarios where cannabinoid therapies intersect with special population considerations, cancer-related symptoms, gastrointestinal disorders, and HIV/AIDS care. Each case offers succinct insights into clinical decision-making, highlighting contraindications, adjunct treatments, favorable terpenes/flavonoids, and outcome measures.

Pediatrics and Developmental Disorders

Case 26: Pediatric Autism with Severe Behavioral Issues

Patient Profile: 7-year-old male with Autism Spectrum Disorder (ASD). New to medical cannabis | Parents prefer a more holistic approach and are informed of the potential developmental risks.

Clinical Complexity: Marked aggression and social impairment requiring multimodal intervention.

Plan: Introduce a CBD-dominant oil at 10 mg/kg/day alongside structured behavioral and occupational therapies.

Favorable Terpenes: Linalool (calming), Beta-Caryophyllene (anti-inflammatory).

Outcome: Significant improvement in aggression and social engagement over 4 months.

Clinical Insight: Take a multidisciplinary, multi-specialty approach to ensure all options are exhausted prior to using cannabinoids in any form. State rules and regulations vary for pediatric patients. Pediatric Behavioral Management—Careful CBD titration can reduce behavioral disturbances in ASD under strict medical supervision.

Case 27: Pediatric Autism with Behavioral Issues

Patient Profile: 10-year-old male with Autism Spectrum Disorder (ASD), severe irritability and aggression. New to medical cannabis | Parents prefer a more holistic approach and are informed of the potential developmental risks.

Clinical Complexity: Ongoing therapy, limited medication choices, parental concerns.

Plan: Continue behavioral and occupational therapies; begin CBD-dominant oil (10 mg/ kg/day) avoiding high-THC products; use beta-caryophyllene (anti-inflammatory synergy).

Favorable Terpenes: Linalool (calming), Beta-Caryophyllene (anti-inflammatory).

Outcome: Marked decrease in aggression and improved social interaction over 4 months. Clinical Insight: Pediatric Behavioral Management—CBD titration can stabilize behavior in ASD patients under strict pediatric supervision.

Case 28: Pediatric Cancer with Chemotherapy-Induced Pain and Nausea

Patient Profile: 10-year-old female with acute lymphoblastic leukemia. New to medical cannabis | Parents prefer a more holistic approach and are informed of the potential developmental risks.

Clinical Complexity: Pediatric oncology setting, severe chemotherapy side effects.

Plan: Trial FDA approved medications. If these fail, consider administering CBD 10 mg/kg/day plus standard antiemetics and analgesics; monitor liver enzymes. Gradually increased to CBD 5mg/kg/day 3x daily and THC 2 mg daily

Note: This THC 2 mg dose can be taken as 500mg in 30ml bottle = approx 2.5 drops or 600 mg in 30ml bottle = approx. 2 drops. See appendix for calculation.

Favorable Terpenes: Pinene (focus, mild airway support), Limonene (uplifting, anti-nausea).

Outcome: Improved pain and nausea control, better adherence to chemotherapy protocols.

Clinical Insight: Pediatric Oncology Support—CBD offers non-psychoactive relief for chemotherapy side effects under strict supervision.

Case 29: Adolescent Cancer with Chemotherapy-Induced Symptoms

Patient Profile: 16-year-old female with acute lymphoblastic leukemia.

Clinical Complexity: Nausea, pain, parental concerns over THC.

Plan: Administer CBD-dominant oil (10 mg/kg/day) plus low-dose THC (2.5 mg BID) sublingually; standard antiemetics.

Favorable Terpenes: Limonene (anti-nausea), Eucalyptol (anti-inflammatory).

Outcome: Improved treatment tolerance over 3 months; mild liver enzyme elevation managed by dose reduction.

Clinical Insight: Adolescent Oncology—CBD/THC combos can be considered. Start with standard antiemetic regimens with careful lab surveillance.

See Appendix for References

Pregnancy and Medically Sensitive Adults

Case 30: Pregnant Woman with Epilepsy

Patient Profile: 30-year-old female with well-controlled epilepsy, newly pregnant.

Clinical Complexity: Potential teratogenic risks of cannabis, maternal seizure control needs.

Plan: No cannabinoid therapy; continue lamotrigine with close serum monitoring by neurologist. Discuss at multiple points in care if benefits exceed the risk; if yes, consider CBD 25 mg daily and slowly titrate up, adding a dose every 2-3 days over 2 weeks; monitoring for improvement.

Outcome: Stable seizure control throughout pregnancy without cannabinoid exposure.

Clinical Insight: Pregnancy Considerations—Cannabinoids remain contraindicated; optimize FDA-approved antiepileptics for maternal-fetal safety. However, note there may be some complex clinical scenarios where the benefits of treating with the lowest effective dose outweighs the risks. Multi-specialty and expert consultation and documentation is recommended in these cases.

Case 31: Elderly Alzheimer’s Patient with Agitation

Patient Profile: 80-year-old female with Alzheimer’s disease and severe behavioral disturbances. New to medical cannabis.

Clinical Complexity: Risk of sedation, polypharmacy, caregiver burden.

Plan: Add THC:CBD oil (2.5 mg THC / 5 mg CBD BID) to existing antipsychotic therapy; monitor sedation levels.

Favorable Terpenes: Linalool (soothing), Eucalyptol (mild anti-inflammatory).

Outcome: Marked decline in agitation and aggression at 3 months; sedation minimized by dose timing.

Clinical Insight: Elderly Dementia Care—Low-dose cannabinoids safely ease neuropsychiatric symptoms with careful monitoring.

Case 32: Alzheimer’s Disease with Behavioral Symptoms

Patient Profile: 70-year-old female with Alzheimer’s disease, experiencing agitation, aggression, and sleep problems. New to medical cannabis.

Clinical Complexity: Managing behavioral symptoms in advanced dementia.

Plan: Continue cholinesterase inhibitors and PRN antipsychotics; add THC:CBD oil (2.5 mg THC / 5 mg CBD gradually titrated to 1 dose in the afternoon and 2 doses at night) with linalool (sedation to help with agitation and sleep ) and add dietary turmeric and quercetin (potential neuroprotection).

Favorable Terpenes: Linalool (soothing), Eucalyptol (mild anti-inflammatory).

Outcome: Decreased agitation and improved sleep in 1-2 months; mild sedation mitigated by lowering THC dose.

Clinical Insight: Elderly Dementia Care—Cannabinoids can help manage behavioral symptoms with careful dose adjustments to minimize sedation.

Case 33: Elderly Parkinson’s Disease with Motor Limitations

Patient Profile: 75-year-old male with Parkinson’s Disease (PD) and comorbid hypertension. Experienced in inhalation routes.

Clinical Complexity: Frailty, risk of orthostatic hypotension, multiple medications.

Plan: THC:CBD oil ( titrated to 5 mg THC / 10 mg CBD BID) | also may consider titrate 1:1 at 10/10 mg dose; adjunct to levodopa and physical therapy (PT). PRN Inhalation Q4 hrs 1-2 puffs.

Favorable Terpenes: Beta-Caryophyllene (analgesic/anti-inflammatory), Humulene (appetite modulation).

Outcome: Reduced tremors and rigidity within 5 days; minimal dizziness addressed by slower titration.

Clinical Insight: Geriatric Parkinson’s—Low, balanced cannabinoid dosing can boost motor function with caution for cardiovascular effects.

Case 34: Geriatric Osteoarthritis with Comorbidities

Patient Profile: 78-year-old female with osteoarthritis (OA), hypertension, and type 2 diabetes with neuropathy. Previously tried topical CBD 100mg per dose OTC and various hemp products without benefit.

Clinical Complexity: Polypharmacy, limited NSAID options, chronic mobility issues.

Plan: Administer start THC 12.5mg Topical 3x/day. After 1 week, add oral CBD oil (25 mg BID), escalated cautiously to 50 mg PRN; continue physical therapy for joint stability.

Favorable Terpenes: Humulene (anti-inflammatory), Beta-Caryophyllene (pain modulation).

Outcome: Moderate pain relief, improved ambulation, no significant interactions. Clinical Insight: Elderly Care—CBD alone can address OA pain without major metabolic conflicts.

Clinical Insight: Note the increased injury and falls risks for cases 30-34. Home health nurse consultation is often valuable to enhance home safety and communication with caregivers.

Oncological Conditions

Case 35: Pancreatic Cancer, Pain, and Depression

Patient Profile: 60-year-old male with advanced pancreatic cancer and experienced cannabis use. Experienced with medical cannabis.

Clinical Complexity: Severe pain, depressive symptoms, concurrent Rick Simpson Oil (RSO) usage.

Plan: Combine THC:CBD oil (10 mg THC / 10 mg CBD TID) with a small RSO dose (~35 mg THC); augment antidepressants.

Favorable Terpenes: Myrcene (enhanced sedation/pain relief), Beta-Caryophyllene (analgesic synergy).

Outcome: Significant analgesia and mood elevation over 4 months; mild euphoria managed by titration.

Clinical Insight: Comprehensive Symptom Management—Cannabinoids can address pain and depression, especially for patients versed in higher THC usage.

Case 36: Esophageal Cancer with Pain and Cachexia

Patient Profile: 55-year-old male with advanced gastrointestinal (GI) malignancy and severe weight loss. No prior experience with medical cannabis.

Clinical Complexity: Dysphagia, malnutrition, intense pain management needs.

Plan: Administer THC:CBD oil (Start at 1:1 5mg dose or RSO Tincture (1⁄2 rice sized), gradually titrate to 10 mg THC / 10 mg CBD BID) alongside nutritional supplements.

Favorable Terpenes: Myrcene (appetite stimulation), Beta-Caryophyllene (anti-inflammatory).

Outcome: Pain relief and appetite boost over 4 months; weight stabilized.

Clinical Insight: Multifaceted Cancer Care—Cannabinoids aid in managing both pain and cachexia in GI cancers.

Case 37: Colon Cancer with Chronic Pain and Anxiety

Patient Profile: 58-year-old female undergoing active treatment for colon cancer. Experienced with medical cannabis.

Clinical Complexity: Tumor-related pain, psychological stress, insomnia.

Plan: Administer THC:CBD oil (10 mg THC / 10 mg CBD BID) focusing on an “indica- like” terpene profile; focus on linalool (anxiolytic) and myrcene (sedative).

Favorable Terpenes: Linalool (anxiolytic), Myrcene (sedative).

Outcome: Pain and anxiety significantly reduced over 4 months; sedation controlled via evening dosing.

Clinical Insight: Dual Symptom Management—Cannabinoids calm both mental and physical burdens, requiring sedation vigilance.

Case 38: Breast Cancer with Pain and Anxiety

Patient Profile: 50-year-old female undergoing active breast cancer treatment. New to medical cannabis.

Clinical Complexity: Tumor-related pain, psychological stress, risk of sedation.

Plan: Administer THC:CBD oil (10 mg THC / 10 mg CBD BID) with an “indica” terpene profile for sedation and anxiety relief.

Favorable Terpenes: Myrcene (sedative, analgesic), Linalool (anxiolytic).

Outcome: Substantial relief in pain and anxiety over 4 months; sedation minimized by bedtime dosing.

Clinical Insight: Breast Cancer Symptom Management—Balancing psychoactivity is key to addressing both physical and emotional strain.

Case 39: Advanced Lung Cancer with Severe Pain and Opioid Dependence

Patient Profile: 60-year-old male with advanced lung cancer, opioid-dependent, high overdose risk. Experienced with medical cannabis.

Clinical Complexity: End-stage disease, respiratory compromise, sedation risks.

Plan: Administer THC:CBD oil (10 mg THC / 10 mg CBD TID) alongside gradual opioid taper using medications like methadone.

Favorable Terpenes: Myrcene (enhanced analgesic effect), Beta-Caryophyllene (supports opioid reduction).

Outcome: 60% opioid reduction with sustained analgesia over 5 months.

Clinical Insight: Opioid-Sparing Strategy—Cannabinoids help manage severe cancer pain while reducing opioid dependence, enhancing patient safety.

Gastrointestinal System

Case 40: Crohn’s Disease with Fistulizing Complications

Patient Profile: 38-year-old male with complex Crohn’s disease and recurrent fistulas. New to medical cannabis.

Clinical Complexity: High-risk Inflammatory Bowel Disease (IBD) requiring immunosuppressants and possible surgical interventions.

Plan: Initiate THC:CBD oil (10 mg THC / 10 mg CBD BID) to complement immunomodulators; administer evening doses to limit daytime euphoria.

Favorable Terpenes: Beta-Caryophyllene (anti-inflammatory), Humulene (anti- inflammatory synergy).

Outcome: Improved fistula healing and reduced abdominal pain over 6 months.

Clinical Insight: Fistulizing IBD—Cannabinoids may support tissue healing and pain relief, bridging medical and surgical management.

Case 41: Crohn’s Disease with Extraintestinal Arthritis

Patient Profile: 40-year-old female with IBD plus arthritic manifestations. Experienced with medical cannabis.

Clinical Complexity: Gastrointestinal flares and joint pain requiring ongoing immuno- modulator therapy.

Plan: Oral THC:CBD oil (10 mg THC / 10 mg CBD BID) and/or Inhaled 30% THC product 2-4 mg per dose - for both GI and joint symptoms. Also topical THC 12.5mg 3-4x/day for joint pain.

Favorable Terpenes: Beta-Caryophyllene (gut/joint anti-inflammatory), Myrcene (analgesic).

Outcome: Notable relief in GI distress and arthritis pain over 6 months; mild euphoria timed at night.

Clinical Insight: Comprehensive IBD Management—Cannabinoids can target inflammation in both gut and joints.

Case 42: Ulcerative Colitis with Severe Flare

Patient Profile: 28-year-old female with acute exacerbation of Ulcerative Colitis (UC). New to medical cannabis except tried CBD 50mg BID without benefit.

Clinical Complexity: High-dose steroid and immunomodulator therapy, risk of rapid deterioration.

Plan: High-dose CBD (up to 200 mg/day) plus low-dose THC (5 mg BID).

Favorable Terpenes: Beta-Caryophyllene (gut anti-inflammatory), Humulene (bowel inflammation).

Outcome: Rapid symptom relief and remission in 2 months; lab results remained stable.

Clinical Insight: Severe IBD—High CBD with mild THC can blunt inflammation, reducing steroid dependence.

Hospice | Palliative Care

Case 43: Palliative Care for Chronic Heart Failure

Patient Profile: 68-year-old female with chronic heart failure, presenting with dyspnea and peripheral edema. No experience.

Clinical Complexity: Advanced cardiac condition, limited pharmacological interventions, risk of fluid overload.

Plan: Administer CBD oil (12.5-25 mg BID) to reduce inflammation and manage symptoms; continue diuretics and optimize heart failure medications.

Favorable Terpenes: Beta-Caryophyllene (anti-inflammatory), Pinene (respiratory support).

Outcome: Improved respiratory function and reduced edema over 5 months; no significant side effects.

Clinical Insight: Advanced Cardiac Care—CBD can aid in symptom management and inflammation reduction in chronic heart failure patients, enhancing quality of life without major interactions.

Case 44: Chronic Kidney Disease with Pain and Itching

Patient Profile: 72-year-old male with stage 4 chronic kidney disease (CKD), experiencing chronic pain and pruritus.

Clinical Complexity: Renal impairment, risk of drug accumulation, managing uremic pruritus.

Plan: Use topical CBD cream BID for pruritus; administer low-dose CBD oil (10 mg BID) for pain management; monitor renal function closely.

Favorable Terpenes: Myrcene (analgesic), Linalool (soothing).

Outcome: Reduced itching and pain, improved sleep quality over 4 months; no adverse renal effects.

Clinical Insight: Nephrology Support—Topical and low-dose systemic CBD can effectively manage pruritus and pain in CKD patients with careful renal monitoring.

Case 45: Chronic Obstructive Pulmonary Disease (COPD) with Anxiety

Patient Profile: 65-year-old female with COPD, experiencing chronic anxiety and dyspnea. Cigarette smoker. Occasional cannabis smoker.

Clinical Complexity: Respiratory compromise, anxiety exacerbating breathing difficulties, limited pharmacological options.

Plan: Administer CBD oil (10-25 mg BID) to alleviate anxiety; also consider adding Indica/Hybrid Indica to reduce risk of increased anxiety. Incorporate breathing exercises and pulmonary rehabilitation. Recommend avoiding inhalation routes but may consider aroma therapy.

Favorable Terpenes: Linalool (anxiolytic), Pinene (respiratory support).

Outcome: Decreased anxiety levels and improved breathing efficacy over 6 months; minimal sedation managed by dose timing.

Clinical Insight: Integrated Respiratory Care—CBD can help manage anxiety related to COPD, improving respiratory function and patient well-being with minimal side effects. Smoking cessation.

Case 46: Chronic Liver Disease with Itching and Fatigue

Patient Profile: 70-year-old male with chronic liver disease, presenting with persistent itching and fatigue. New to medical cannabis.

Clinical Complexity: Hepatic impairment, managing pruritus without exacerbating liver dysfunction, fatigue impacting daily activities.

Plan: Administer CBD oil (20-25 mg BID) to reduce pruritus and manage fatigue; continue ursodeoxycholic acid and optimize liver-supportive therapies. Add 2.5-5 mg THC PRN Sativa to help with fatigue and mood.

Favorable Terpenes: Beta-Caryophyllene (anti-inflammatory), Humulene (appetite stimulation).

Outcome: Significant reduction in itching and improved energy levels over 5 months; liver function tests stable.

Clinical Insight: Hepatology Support—CBD can alleviate pruritus and fatigue in chronic liver dz patients while maintaining hepatic stability through careful dosing.

Clinical Notes on End-of-Life Care: Palliative care is a specialized medical care focused on relieving symptoms and improving quality of life for patients with serious illnesses, alongside curative treatments. Hospice care is end-of-life care that prioritizes comfort and support for terminally ill patients, typically with a prognosis of six months or less. Although training may vary, in my training, palliative care can continue alongside disease-modifying treatments, while hospice care typically begins when life-prolonging treatments cease. In either case, patients often benefit with medical cannabis.

For patient cases in end stage disease, hospice, palliative care, and other complex medical cases, it may be worthwhile to discuss care for the caregiver - respite care with family, friends, spouses and significant others.

Infectious Diseases (HIV/AIDS)

Case 49: HIV Patient with Depression and Chronic Pain

Patient Profile: 45-year-old female with HIV/AIDS and persistent pain. New to medical cannabis.

Clinical Complexity: Comorbid depression, immunocompromised status, potential for polypharmacy.

Plan: Use THC:CBD oil (5 mg THC / 10 mg CBD TID) alongside antidepressants and standard pain regimens. Incorporate regular exercise to enhance endocannabinoid tone.

Favorable Terpenes: Myrcene (analgesic), Limonene (uplifting mood).

Outcome: Notable improvement in mood, pain control, and overall quality of life after 6 months; minor euphoria resolved by dose revision.

Clinical Insight: Comprehensive HIV Care—Cannabinoids address depression and pain concurrently, requiring vigilance regarding drug interactions. Exercise and cannabinoids can synergize for better mood and pain control, needing careful dosing.

Case 50: HIV Patient with Neuropathy and Weight Loss

Patient Profile: 50-year-old male with HIV/AIDS, experiencing peripheral neuropathy and significant unintentional weight loss. Experienced with inhalation but never tried oral medical cannabis.

Clinical Complexity: Antiretroviral therapy-induced neuropathy, malnutrition, risk of opportunistic infections.

Plan: Administer THC:CBD oil and/or edibles (10 mg THC / 10 mg CBD TID and PRN additional 10mg THC) to manage neuropathic pain and stimulate appetite; continue antiretrovirals and nutritional support.

Favorable Terpenes: Myrcene (appetite stimulation, analgesic), Beta-Caryophyllene (neuropathic pain relief).

Outcome: Reduced neuropathic pain by 50% and stabilized weight over 5 months; improved adherence to antiretroviral therapy.

Clinical Insight: Advanced HIV Management—Cannabinoids can effectively manage neuropathic pain and counteract weight loss, enhancing patient adherence to antiretroviral regimens while monitoring for potential side effects.

Summary

This organizational structure categorizes each case based on the relevant body part or organ system, with dedicated categories for Pediatrics and Developmental Disorders, Palliative Care (Non-Cancer), and Infectious Diseases (HIV/AIDS). This ensures comprehensive coverage and facilitates targeted application of pain management and cannabinoid therapy strategies. Each case is uniquely represented to prevent overlap and ensure clarity.

Final Observations

From pediatric to geriatric care, from HIV/AIDS to advanced oncology, these cases illustrate how cannabinoids—synergistic with targeted terpenes and flavonoids—can be incorporated into complex comprehensive treatment plans. Rigorous monitoring and tailored dosing ensure efficacy while minimizing risks, underscoring the value of cannabinoids in modern, patient-centered medicine.