Question about fentanyl patch

[sukichaz]

Dear hospice nurses,

Some of you were very helpful to me about 6 weeks ago when I posted a question about my mother being able to get a pleural tap while receiving hospice services. (That thread is at: https://allnurses.com/forums/f25/question-about-dyspnea-215167-new-post.html)

This is sort of a followup. In brief, if you don't read the background at the above thread--she is 82, has metastatic breast cancer and has recovered from several crises in the past 20 years. I don't know if she'll recover this time, but she is fighting. We've given up in the past & she's recovered, so although she has become cachectic, and is using O2 X 2 months now, she seems to have a very strong constitution.

First my questions, then background:

1) fentanyl patch: how is it usually tapered down? Is it feasible to taper from 25 by putting on a 12.5, then putting on a second 12.5 if the first is not adequate? If not, then how is it usually done?

2) is fentanyl used as morphine is, for dyspnea? We are concerned because of the sedative effect of the fentanyl. Some shorter acting medication might be preferable?

What led to this: She did have a pleural tap about 10 days ago, hospice was revoked and then she started hospice again after the procedure. She was d/c to home yesterday. Pain has never been an issue, but of course she needed pain relief after the chest tube, and is now on fentanyl 25 mcg, with OxyFast for breakthrough pain. Initially, because she still had some pain on the 25 mcg patch, the pulmonologist had upped it to 50. My dad appealed to me to intervene because she was oversedated then, and the doctor refused to listen to his concerns, said, "I'm the doctor and you don't know anything about this." I've had to step up to the plate like this before with doctors or nurses in the past, unfortunately, so I did intervene. We were able to get the regimen changed to the present one. Now we are wondering when and how the fentanyl can be taped off and stopped, as a quality of life issue. And, we suspect the hospice folks want her to stay on it. We really don't want to have a conflict with them over it.

THis is how she is today: On fentanyl 25, she is still drowsy and is unsteady on her feet. She falls asleep while watching TV, but her appetite is still good, and if you talk to her, she converses normally, then falls asleep again. Knowing her baseline, it's very hard for us to figure out if this is advancing disease, or the opioid, but we tend to believe it's the latter. She has, and has for several years, had dyspnea, due to lung involvement and some CHF. She is having no pain and has not needed the Oxyfast for at least the past 2 days.

Is there some school of thought in hospice that the person should spend indefinite periods of time on powerful opiates? Are there some hospice nurses who think the patient is better off on Cloud 9, or is that just my impression? From what my dad is reporting I am wondering if the hospice nurses are lumping my mother in with people who have chronic cancer pain, and are reluctant to consider tapering off the opioids. My dad is frustrated and concerned that he is being cut out of the loop: the hospice nurse says she will only discuss my mom's care with my mom. He has no concerns about addiction and does want her medicated if she has pain, but once the pain is over, he doesn't want her on the patch anymore.

He now wants me to go there and intervene with the hospice nurse when she visits tomorrow. I would like to be able to speak to her with a little more knowledge than I now have.

Any thoughts?

Thanks,

Stephanie

[tencat]

Hi. I'm sorry that you are having to go through this.

The most important question to ask, I think, is: What does (or would, if she's not able to make her own decisions) your mother want? If she were my patient I would have no trouble trying to lower the dose IF she wants to do that. It's a delicate balance between pain and lucidity. You don't want her to be alert but in horrid pain. Of course, one can always up the dose again. But the point is that what the patient wants is what is most important to the nurse caring for her. If the patient and the family don't agree, then most of us will support the patient's choices and wishes. I don't know if your mother is able to make her own decisions or not, but if she is, then the nurse caring for her should be listening to what your mom wants.

Darlin', your mother is 82 years old and has lived a good, long life. At this point, there is no issue with becoming 'addicted' to the medication, and if pain is an issue, the pain should be managed. There is no 'cure' for her. The best thing you can do is keep her comfortable and love her.

[NRSKarenRN, BSN, RN]

sounds like a family meeting with hospice staff is surely needed here.

hospice is about preparing the patient and family (along withsupportive friends/caregivers when desired) to maximize patients quality of life and health needs when one has a life limiting illness. to exclude your father in pain management discussions does a disservice to both of them.

part of the issue appears to be you and family's concerns regarding pain management: "over sedation", "powerful opiates," "no concerns about addiction and does want her medicated if she has pain, but once the pain is over, he doesn't want her on the patch anymore", "now we are wondering when and how the fentanyl can be taped off and stopped, as a quality of life issue", "lumping my mother in with people who have chronic cancer pain". these are very conflicting statements showing a partial understanding of pain management and lack of understanding of metastatic breast ca disease process which can be very painful as disease progresses.

many patients needing chest tubes require meds upon insertion and removal with pain often controlled with tylenol or tylenol with codeine. i've not seen a patient placed on fentanyl patch for just chest tubes as oral meds preferable for short term duration of treatment. i suspect however that level of pain your mother experienced is due to effects of metastatic breast ca evading into chest wall and that is why med given for it's consistent dosage, avoiding peaks and valleys of oral meds and physicians expectation that due to disease process would need this type of medication management long term

you state that mother has no pain, not needed breakthrough meds which is good showing patch is working and prior pain is controlled. however, you've left out discussions what your mother has been saying about her overall pain experience. from your description of mothers health and hospice experience with advanced breast cancer patients, its very rare that they have no pain. is your mother desiring to stop the patch?

fentanyl and morphine are helpful with dyspnea.

if she otherwise comfortable, not short of breath, not restless, eating and drinking and enjoying daytime activities:tv, reading book, music , brief conversations then i think the pain regimen is working and patient comfort achieved.

your story strikes home with me ...reminds me of a family i worked with that had same concerns: is it the pain meds causing drowsiness, easily falling asleep and unsteadiness or is it the disease?

only way to know for sure is with agreement of patient to try decreasing patch to 12.5 mg or switch entirely to equal analgesic oral meds which can be tapered downward. it make take 16-32 hours for this dose to be out of system. i would look for breakthrough pain if it occurs to start on day 2-3 after reducing dose along with expectation of less drowsiness and steadier on her feet. if symptoms don't improve by day 4, then one can expect it's illness and not meds.

some resources to help you:

avoiding misconceptions in pain management

one main reason for this under treated pain is the existence of several myths and misconceptions regarding pain management. goal of this summary to dispel these myths and misconceptions.

free registration required.

http://www.medscape.com/viewarticle/418521

quality of life - pain

quality of life breast cancer model

pain management - what everyone should know

advanced cancer and palliative care treatment guidelines for patients

symptoms during a fatal illness

time course of dying

managing symptoms for a "good death"

wishing you and your family peace, love and support during this journey.

[sukichaz]

Thanks NRSKarenRN,

Actually, my mom has had no pain at all prior to having the pleural tap. Her problem was solely dyspnea. I guess that is unusual, but there's no reason patients have to fit into a preconceived pattern.

My mother is quite lucid and keeps up with current events better than I do. She speaks for herself and definitely makes her own decisions about her care. My father and I both questioned using fentanyl transdermal since it is not indicated for postsurgical pain and or in opiate-naive patients, since we were in a position to read the prescribing information and mom was not. The family doctor started her on the patch, not a pain specialist, and this is a doctor I privately consider mediocre in her practice, from many past experiences.

From what you have said, I think it is quite likely that the hospice providers are assuming that she is having cancer pain because they have made an assumption that every breast cancer patient has cancer pain. This explains why, from the inception of hospice services in March, the nurse would ask about pain at every visit. This had my parents bewildered and understandably led my father and me to wonder if this nurse was truly in touch with the situation.

From what another person said to me as a response to my question, there are obviously some hospice nurses who must think that because a person has lived a long life, that it's fine for them to die. However, my mom has made it very plain that she wants to stick around for as long as possible, and she was doing housework and had independent ADLs until going in for the pleural tap 10 days ago. In light of this, when nurses have said to my dad things to the effect that: "what do you expect, she has metastatic cancer" it comes across as shockingly insensitive and out of touch. So yes, we do have concerns about powerful narcotic drugs, and with hospice nurses who seem to be eager to administer them and at the same time have written my mother off, it's no wonder my dad calls the visiting hospice nurse the "angel of death." I'm old enough to remember terminally ill patients being deliberately "snowed" in inpatient units. I am starting to wonder if this is still going on under the guise of symptom management.

So I do appreciate your suggestions about tapering. We want to take things a day at a time, respect my mom's wishes, and act according to the situation.

[sukichaz]

Tencat, thank you for taking the trouble and care to respond, but I have to point out to you that I originally stated that addiction is not a concern we have. Alsok, it may seem to you like 82 is extremely old, but age in years and level of functioning have little relationship. There are people in their 90's who live at home and function independently.

[AtlantaRN, RN]

my best friend, Ruth is 91 this month, and she is still independent. She is a pip.

linda

[EmptytheBoat]

Dear Sukichaz,

I'm sorry your Mom (Happy Mother's Day) is going through this but what a loving and supporting family she has. To answer your questions: (1) You

don't necessarily need to taper down the Fentenyl patch, if your Mom is not having any pain, you may discontinue. You mentioned you had Oxydose and

that may be used for any acute pain your Mom may have. Oxydose is a quick-acting pain medication and is not sustained so frequent dosing may be required if your Mom has consistant pain. I would suggest another short-acting medication such as Lortab or Darvocet on an as-needed basis, these meds provide more sustained relief and will help you provide better pain management. (2) Fentenyl is a derivitive of morphine and may be used for

dyspnea, but in patch-form, is not the preferred route for acute dyspnea.

Yes, I believe a shorter-acting medication would be preferable. For dyspnea,

I like to use Ativan/Xanax, either scheduled or prn, starting low and titrating

if needed. These medications may also cause sedation, but usually not as much side-effects as the opiates.

Best wishes to your Mom and family, God speed.

[ginger58, ASN, RN]

I'm surprised also that Fentanyl patch would be used around a procedure. Where I worked we weren't allowed to use it unless the patient was on a lot of BTP meds or had already been on chronic pain meds.

I hope your concerns get resolved very soon and you can enjoy your mom for a time.

[aimeee, BSN, RN]

I'm surprised also that Fentanyl patch would be used around a procedure. Where I worked we weren't allowed to use it unless the patient was on a lot of BTP meds or had already been on chronic pain meds.

I hope your concerns get resolved very soon and you can enjoy your mom for a time.

I thought the same thing. Still, I am sometimes appalled at what I read in the history when patients come to us. Saw one doc had gone straight from a couple vicodin a day to a 50 mcg patch! And then they wonder why the patient is obtunded!

[caroladybelle, BSN, RN]

First, I don't recall ever seeing a 12.5mcg fentanyl patch.

Second, fentanyl patch is sometimes used for dyspnea, but the patch isn't generally used for procedural pain as it does not start fast enough, nor wear off fast enough. It should be used for chronic issues.

Third, is Mom more comfortable with the fentanyl or would she prefer not having it?

Fourth, if she is having frequent reoccurrances of malignant pleural efffusions, there is new chest tube used for palliation. I believe that it is called a pleurex tube, that can sometimes allow the patient to stay home and have the fluid drained, rather than repeatedly hospitalized for drainage. It is also a much smaller tube with less discomfort - stays clamped and under a sterile dressing - and drained when the patient develops dyspnea d/t pleural effusion. A family member/home nurse drains it using a kit. It would also not interfere with a hospice order as it is a comfort measure.

I will keep you and your mother in my prayers.

[aimeee, BSN, RN]

First, I don't recall ever seeing a 12.5mcg fentanyl patch..

Carol, the 12.5 mcg dosage patch is fairly new....it just came on the market about a year ago, I think. Hospice pharmacia did not include it in their formulary until this year.

Good mention about the http://www.denverbio.com/physician_pleurx_catheter.html

pleurx system.

[ginger58, ASN, RN]

The Fentanyl 12.5 mcg/hour patch has been on the market for awhile but not all pharmacies carry it. I have really only used it for pain.