Pain_control_overview

Seizing child recieving IN treatmentTherapeutic Intranasal Drug Delivery

Needleless treatment options for medical problems

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Intranasal Pain Medications Overview

Topic summary:

Nasal delivery of pain medication is an attractive form of pain control in settings where patients are suffering severe pain, yet do not have any IV access. Typical situations include hospice care at home, clinic settings where a painful procedure or dressing change is needed, EMS treatment of the injured or burned patient (especially children), Emergency treatment for orthopedic trauma, burns and pediatric painful conditions. There is now extensive literature on this topic (reviewed on this website) showing IN pain control is as effective as IV pain control, faster in onset in the situation where an IV does not already exist, can be titrated, and more commonly given in settings where concerns regarding IV start or IV opiates occur (small children with severe pain). Furthermore, the drugs can be reversed by intranasal naloxone if a problem arises. The most extensively studied intranasal medications are fentanyl and diamorphine. Other moderately well studied medications include sufentanil and ketamine. This overview section provides a quick look at the topic and provides dosing and protocols. Digging deeper behind this page is an extensive review the literature with supporting references (Click here to skip the overview below and to go directly to the deeper discussion).

Key Concepts regarding delivery of any nasal medication to the systemic circulation and brain

Use the right dose!

Minimize volume, maximize concentration of the drug

Large volumes are lost into the pharynx or out the nostril.

Maximize total absorptive surface area

Use a delivery system that maximizes mucosal surface area coverage and minimizes loss to the environment and runoff

Be thoughtful about anatomic issues and head positioning to enhance delivery

 

Key Concepts related to nasally delivered pain medications

Dosing: The dose for nasal drug is higher than IV drug. This occurs because not all the drug is absorbed and that which is absorbed takes longer and peaks at lower levels in the blood stream. See below for doses supported by the literature. Failure to use the adequate dose will likely lead to failure to control pain.

Respiratory depression: Generic fentanyl delivered intranasally does not lead to respiratory depression. Click here for a brief but more in depth discussion on this concept. However, the new highly concentrated patented nasal formulations of fentanyl, and generic sufentanil (already highly concentrated) can cause respiratory depression so require more careful administration.

Nasal burning: The nasal opiates are tolerated very well and do not burn.

Titration: Repeated doses given every 10-15 minutes for the opiates can lead to more titrated effect in essentially the same fashion as is done with IV opiates.

Reversal: An extensive amount of literature exists showing that opiate induced respiratory depression can be reversed with nasal naloxone. that data is available on this website under the opiate overdose tab.

Dosing information and delivery protocol

Weight based protocols and dosing table for intranasal fentanyl, sufentanil and diamorphine (click here)

Commonly used generic intranasal medications - single page dosing summary (click here)

In Depth literature review, discussion, bibliography (Click here)