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Nonstandard medication delivery
JAMES R. MINER
n Delivery routes
n Rectal
n Nasal
n Nebulized/inhaled
n Transmucosal
n Transdermal
n Introduction
This chapter addresses delivery of analgesics via a variety of “nonstandard”
routes. Since the focus is on systemic drug delivery, useful regional
approaches (e.g. locally active topical therapy, nerve blocks) are not discussed
here. The vast majority of medications are administered orally or
parenterally. Oral therapies are most commonly employed, since they are
convenient and inexpensive for patients who can tolerate PO intake. When
pain is severe, however, analgesics must be given immediately and titrated
to effect.
As outlined in other chapters of this text, the IV (not IM) route is indicated
in the context of need for rapid and titrateable analgesia. Injections IM may
have some occasional utility when IV access is difficult, or when rapid
analgesia is unnecessary. However, the IM route’s ease of use is largely
offset by injection pain, titration difficulty, and delayed onset of action.
Unless IV access is difficult, there is usually little reason to recommend the
IM route.
Situations may occasionally arise in the ED in which IV placement is either
too difficult or best avoided for other reasons. This scenario is encountered
most frequently in children, who often do not tolerate IV placement attempts.
While non-IV routes for delivery of analgesics such as opioids are not
superior (and sometimes do not reach equivalence) to the IV approach,