Confusion caused by Fentanyl ? - 1251660

charvnc
Posts:15

Hospice increased the fentanyl patch dosage to 150 mcg/hr last Tuesday - my husband started having some additional confusion on Wednesday and some stomach discomfort on Thursday - this morning he is more disoriented (confused about recent events etc.) and threw up (first time in months). I called the hospice nurse and she said it was probably the fentanyl increase (but possibly brain mets) and that it should resolve in a few days. I don't know if I should wait or cut back to 125 mcg/hr - we are using oxycodone for breakthrough pain and it doesn't cause him confusion like this? Any ideas or suggestions?

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Reply # - December 21, 2012, 06:59 AM

charvnc
Posts: 15

... I updated my profile and the signature disappeared AGAIN....

here it is FYI - I don't remember how to fix it

My husband was diagnosed Jan 08 SCLC Limited - Chemo and 2x daily Radiation, PCI June 08/ Recurrence late 09 in adrenal - change to Extensive - Radiation only/ Recurrence Nov 10 - Adrenal only - surgery to remove Jan 11/ Recurrence multiple locations - repeat 1st line chemo June - October 11/ PET scan Feb 12 - NED!
Keep HOPE alive! Update 5/14/12 - Recurrence multiple locations - started Topotecan Update 9/28/12 - Completed 6 rounds, but PET scan revealed progression while receiving Topotecan - Started Hospice in October

Reply # - December 21, 2012, 01:46 PM

catdander
Posts:

charvnc, I thought I'd commented on this though it must admit I don't remember sending it.

I'm so sorry your husband is having such difficulty controlling pain. It sometimes takes a couple of days for your body to adjust to opiates or new doses of opiates. Also people react to different opiates differently and need to try other options to find what works best. oxycodone, morphine, fentanyl, and methadone are the ones that come to mind.

As you probably know it is a matter that needs to be addressed with the healthcare providers. And if you feel you should move up the chain of command to get his stomach upset eased quicker, don't hesitate. I'm under the impression that it's as important as you think it is.

I will ask one of our palliative care doctors to comment on whether there is one that tends to be easier on the tummy.

Much love and peace,
Janine

Reply # - December 21, 2012, 03:13 PM

Dr West
Posts: 4735

charvnc,

I think this is a hard one. It might be possible to know more if I were among the docs directly involved, but I'm not sure anyone could really know. I think it would be reasonable to pull back on the dose of the fentanyl patch, which could absolutely be the leading cause, but it takes many hours or even up to a day to have the dose changes, whether going up or down, really kick in -- so you wouldn't necessarily see a rapid turn-around.

It's also possible that the symptoms could be from brain metastases, but the most likely way to know would be to make the changes in the meds and see whether things improve or not. Or possibly a repeat brain scan could show a marked change...though sometimes there's push back about doing scans on people who are on hospice. You often need to justify how it would change what you do. But if you knew that there was a lot of edema around new or growing brain metastases, adding or increasing steroids could be a big help.

Good luck.

-Dr. West

Reply # - December 21, 2012, 05:15 PM

charvnc
Posts: 15

Thanks for the responses Janine and Dr West - the stomach problems seem to have resolved, but his confusion and unsteadiness is still pretty bad today. After talking again with hospice we've (my son and I) decided to give it another day or two to see if he adjusts to the increased dose - since pain control is what we are trying to accomplish and his pain is better with this dose. If it doesn't get better we'll probably reduce the patch back to 125 mcg/hr and see if that helps his confusion.

Reply # - December 22, 2012, 03:13 AM

Dr Harman
Posts: 12

charvnc,

I agree with what Dr. West has mentioned. Any significant changes in opioid dosing can cause more prominent side effects (like the confusion and unsteadiness) in the short-term, ie 2-3 days, but those do improve as the body adjusts to the new drug level. Fentanyl is challenging at times because titrating the dose takes a longer time because it is so long-acting. I think your plan is wise. I hope he is feeling more steady soon.

-Dr. Harman

Reply # - December 22, 2012, 10:15 AM

double trouble
Posts: 573

My Daughter In Law throws up every time she take a strong pain killer. She has had Phenergan added to counteract that reaction. Would this be helpful here?

Debra

Reply # - December 22, 2012, 05:22 PM

Dr West
Posts: 4735

Sometimes we add frequent anti-nausea medications, potentially even on a standing (scheduled) basis rather than just "as needed". It's a fine thing to try, whether phenergan or another anti-nausea medication.

-Dr. West

Reply # - December 23, 2012, 05:10 AM

charvnc
Posts: 15

The nausea and stomach upset has resolved so I'm thinking that that symptom was just something he ate or a stomach bug - but the confusion and poor coordination seemed worse yesterday. I was looking over his many medications - reading their side effects (always a mistake) and saw that gabapentin can cause confusion - I called the weekend hospice nurse again and discussed it with her - she called our oncologist, who happened to be on cal this weekend. He said he didn't think it was the gabapentin and that I should monitor the oxycodone I'm giving for breakthrough pain - to see if the confusion is worse after I give it. He also prescribed Dexamethazone so I'd have it on hand, but said to wait until today to see if I could establish whether the oxycodone was the problem. It's hard to figure out since usually when he takes oxycodone he goes right back to sleep. He does seem better this morning - just came out and fixed himself a cup of coffee - but I'm glad to have the steroid if we need it. I don't guess it would hurt anything to give it to him - probably help his appetite and bad knee but steroids usually mess up his sleep - or at least they did with chemo. If it is a brain met, it would help with the swelling and help him. So now I guess it's wait and see -
Hope everyone at Grace has a Merry Christmas - and thanks for being there.

Reply # - December 23, 2012, 06:45 AM

certain spring
Posts: 762

So sorry you're having this trouble, which must be very upsetting.
For what it's worth, I can string a sentence together on Fentanyl, but on oxycodone I really can't.

Reply # - December 23, 2012, 08:53 AM

catdander
Posts:

Another thought about the doctors suggestion about playing the oxy dose is it acts much quicker than the fentanyl. You'll be able to see the difference in the way the extra or less doses affect his behavior.

Interesting certain spring. I'll keep that in mind.

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