My mother was diagnosed in Nov 2012 with stage IV NSCLC (an extremely rare, aggressive subtype we were told). She was admitted to the hospital a few weeks later for pain management. Palliative care doctors put her on 15mg, 3x a day of Methadone, 300mg of Fentanyl every 72 hours, 4mg Dexamethasone daily, and 4mg Dilaudid as breakthrough medication. My mother also underwent 13 sessions of radiation to treat the underlying cause of the pain, and had undergone 2 rounds of chemo (Avastin, Taxol, Carboplatin).
She never fully regained lucidity throughout the treatment, and experienced visual hallucinations, confusion, extreme fatigue, difficulty focusing. She was on these dosages for about 3-4 weeks before her oncologist started weening her off. He reduced Methadone to 15mg 2x a day for one week, then down to 10 mg 2x a day for a week. He also reduced Dexamethasone from 4mg a day to 2 mg a day for a few days, then reduced it again to 1mg a day for a few days. He then reduced Methadone to 5mg 2x a day and Dexamethasone to 0.5 mg a day.
Last week we had to have her hospitalized because the confusion and delirium worsened to the point that she did not know who she was, where she was, what was going on around her, and did not recognize any of us. The doctor removed Methadone and dilaudid completely, as well as Lexapro (20mg a day). It has been about 5 days, and she has not shown much improvement in terms of her confusion and delusions. An MRI of her brain showed 6 small tumors that had not been present in December, but her oncologist said that they are small and there is no edema around them, so he doesn't think that they are causing the level of confusion that my mother is experiencing.
I'm wondering if anyone has seen anything like this, and if you think that this is medication induced, caused by brain metastasis, or possibly both, and if there is reason to hope that her cognitive function will return. We are considering WBR and weening off of the Fentanyl.
Reply # - February 18, 2013, 01:13 PM
Reply To: Opioid side effects and withdrawal
I'm so sorry mtc, It sounds like a very difficult situation. I wish I did but I don't have anything to offer.
I will contact a doctor for input. You should hear back within the day.
With hope,
Janine
forum moderator
Reply # - February 18, 2013, 01:57 PM
Reply To: Opioid side effects and withdrawal
Hi tmc, thanks for sharing your mother's story. I am sorry to hear that she is having such a rough time. You did not comment on her age or other medical problems, but I will assume that she is relatively elderly.
Delirium is described as a state of being confused and being unable to pay attention to what is going on long enough to really understand what is happening around you. It can be caused by a great many things that are very common in cancer patients, and a number of them are in play in your mother's case. In most situations more than one thing is contributing to the problem. Medication-related delirium is very common and even more common when someone is being treated with multiple medications that can affect the brain, such as pain medications, steroids, sedatives, and psychiatric medications like antidepressants. Both the medications themselves and withdrawal from some medications (i.e. narcotics, benzodiazepines, and antidepressants) can contribute. Elderly patients are at higher risk of delirium than younger patients, and other health issues such as infections also tend to make things worse. Another common cause is disruption of the sleep/wake cycle where patients sleep all day and are awake at night when it is dark and confusing.
As for brain metastases, actually delirium is an uncommon symptom, especially when the lesions are small and not causing much swelling. Sometimes steroids that are given to prevent swelling can cause delirium, but I would usually look at other causes before attributing delirium to brain mets alone.
Delirium can be very serious, and should be treated aggressively. Antipsychotic medications can help patients with the symptoms of delirium, and the underlying cause needs to be addressed. Minimizing medications that cause delirium is important but also avoiding rapid removal of long-standing meds that may cause withdrawal is also important. Sometimes trial and error is the only way to figure out what works.
Good luck!
Reply # - February 20, 2013, 02:31 PM
Reply To: Opioid side effects and withdrawal
As Dr. Pennell describes, there are many potential causes of delerium. Further, it's possible for more than one cause to contribute for a particular patient. You have listed some potential causes--cancer, brain mets, and pain medicines. There are MANY others and it is the job of her doctor to evaluate which may be present, so as to try to reverse them. It's impossible to list all of them, as almost anything that disturbs the natural balance of the body can cause delerium. However, common causes included changes in environment (such as hospitalization), infections, metabolic derangement (kidneys and/or electrolytes being off), pain, and medicines (yes, pain medicines are high on this list, but other meds and their interactions are also on it).
As a final point, the elderly are more susceptible to delirium. The older brain often requires very little "insult" to go become delirious and can take a long time to recover.