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72 Nonstandard medication delivery
n Nebulized/inhaled route
The practice of delivering opioids via a nebulizer has been discussed in the
literature for over a quarter of a century. 25 For myriad painful conditions,
ranging from sickle cell crisis to cancer and even undifferentiated abdominal
pain, nebulization of opioids such as morphine (10–20 mg) or fentanyl (1.5–
3.0 μg/kg) is shown to be safe and effective. 20,26–32 Compared with IV administration,
nebulization of the opioids achieves roughly equivalent pain relief,
with similar times of onset. 20,28–31 The use of a breath-actuated delivery system
has proven safe and effective and seems particularly attractive for ED patients
who are old enough (about three years of age) to use the system. 32
Nebulized naloxone has been described for the reversal of opioid
toxicity. 33
n Oral transmucosal route
The OTM administration of fentanyl is perhaps the best described of the
alternative dosing strategies. Since they were developed for breakthrough
cancer pain, many currently available OTM fentanyl formulations are too
potent to be safely given to opioid-naïve patients. 34,35 There is, however,
potential utility for this administration route. For instance, one study of
(opioid-naïve, noncancer) trauma patients showed OTM fentanyl (1600 μg)
to be similarly efficacious to standard IV dosing, over a period of 5 h. 36 A
recent trial in children found that OTM fentanyl (10–15 μg/kg) provided
analgesic efficacy superior to that achieved with IV morphine (0.1 mg/kg). 37
The study’s authors noted relatively few adverse effects (17% overall rate of
nausea/vomiting or pruritis with OTM fentanyl), but appropriately point
out that their patient sample of 87, with 47 taking OTM fentanyl, is too small
to serve as conclusive demonstration of OTM fentanyl’s safety.
n Transdermal route
The TD administration of buprenorphine and fentanyl has been been well
described, but the onset of action is too prolonged for routine use of this