Medication Route Error

allnurses Guide · Dec 27, 2023

klone said:

Are you going to do anything about the fact that it is ordered to be crushed and swallowed, which is NOT how a SL med is supposed to be given?

SL suboxone taken orally risks ineffective absorption and withdrawal symptoms. Maybe a lit review presented to the ordering physician is in order.

As nurses, it is our duty to use evidence to guide our practice. Blindly following physician's orders that our incorrect is not prudent nursing practice, and could result in disciplinary action or loss of license if it results in patient harm.

I was going to say something similar but the OP left. Still it's a great topic to discuss. We give a number of sublingual meds in psych and some of the nurses I work with don't understand the SL route, give it wrong and then can't figure out why it's not working.

Also can we please stop asking for advice and support when what we really want is people to co-sign our behaviors and opinions. Good advice includes criticism which leads to change in practice. Ie better nursing outcomes.

I am not here to hold anyone's hand.

Hppy

OneRN50 · Dec 27, 2023

It is done this way in Corrections...I didn't make these rules..it is so highly diverted....these orders came down from the powers that be

allnurses Guide · Dec 28, 2023

OneRN50 said:

It is done this way in Corrections...I didn't make these rules..it is so highly diverted....these orders came down from the powers that be

Yeah that's what people like to say to absolve themselves I would quit a job that made a rule to administer by the wrong route.maybe you don't know this but SL tabs dissolve once in contact with the mucus membrane any liquid given for 10 minutes before or 10 minutes after delays and changes the effectiveness making the medication useless. Since this medication can't be absorbed when desolated in water why give it at all. Above all else nurses are educators and that includes bringing up valid concerns.

JKL33 · Dec 28, 2023

hppygr8ful said:

Since this medication can't be absorbed when desolated in water why give it at all. Above all else nurses are educators and that includes bringing up valid concerns.

My take was that it usually isn't mixed with water -- that's the part that OP was acknowledging as the error. I took it that they're usually crushing the med and administering it SL so that inmate cannot put the tab under tongue and walk away and immediately remove it before it can dissolve.

Still...the drug info says not to cut, chew or swallow the SL tab; surely crushing produces about the same result as chewing so it seems like the mfr has stated this should not be done

allnurses Guide · Dec 28, 2023

OneRN50 said:

It is done this way in Corrections...I didn't make these rules..it is so highly diverted....these orders came down from the powers that be

I understand about following rules but more mistakes and atrocities (Which you problem is not) have been committed by people who were just following rules.

I did a brief lit review last night and could not find in scientifically based evidence that supports the above note quoted.

guest1039278 · Feb 8, 2024

I know I am SUPER late to the game here but aren't suboxone tablets small-ish?

Couldn't you crush the pill and then pour the contents of powdered/finely-granular into the mouth and under the tongue and then have the patient sit there with the mouth closed for like 30-60 seconds?

The saliva would emulsify the tiny little specs of powdered and granular suboxone and make it INCREDIBLY difficult for the patient to physically retrieve the medication from under their tongue and divert it without significant waste.

You would significantly increase the difficulty of diverting the med while maintaining sublingual exposure of the medication for proper absorption.

I mean, this is PURE speculation and I am not a pharmacist but I would probably ask a pharmacist if this method would be sufficient to maintain the effectiveness of the SL route just to be safe. But the way I see it, the raw medication is still going to the exact right place. Just a thought. Maybe see if you pharmacist would be on board and get them to back you up about NOT doing true PO route.

guest1039278 · Feb 8, 2024

I know I am SUPER late to the game here but aren't suboxone tablets small-ish?

Couldn't you crush the pill and then pour the contents of powdered/finely-granular medication into the mouth and under the tongue, and then have the patient sit there with the mouth closed for like 30-60 seconds?

The saliva would emulsify the tiny little specs of powdered and granular suboxone and make it INCREDIBLY difficult for the patient to physically retrieve the medication from under their tongue and divert it without significant medication waste.

You would significantly increase the difficulty of diverting the med while maintaining sublingual exposure of the medication for proper absorption.

I mean, this is PURE speculation and I am not a pharmacist but I would probably ask a pharmacist if this method would be sufficient to maintain the effectiveness of the SL route just to be safe. But the way I see it, the raw medication is still going to the exact right place. Just a thought. Maybe see if your pharmacist would be on board with something similar and get them to back you up about NOT doing true PO route when confronting the prescriber.

To me, swallowing suboxone is like taking 10mg of IV hydralazine for hypertensive crisis and instead of giving IV, you pour the med out of the syringe onto the back of the patient's hand while HOPING the med will sufficiently absorb trandermally before you have a negative patient outcome. Hard to rationalize this if *** hits the fan legally.

I have seen providers in prison/jail systems get sued and deposed for issues related to the incarcerated patients they were treating so by NO means should anyone expect that as a nurse or provider you are immune from scrutiny/litigation/discipline for knowingly providing ineffective and improper care of your incarcerated patients.

If an incarcerated patient decided to sue/report/complain regarding the medical care they received (in this case, worsening OUD withdrawal symptoms and/or pain due to improper/inneffective interventions), I would say that provider might have some explaining to do.

Giving a patient (who you actively inform will be given a genuine treatment for a diagnosed condition) what is essentially a placebo knowing it will NOT treat the diagnosed condition (whether it be placebo by chemical/route/preparation/etc) outside of a controlled medication trial requiring a placebo group could be a real problem that the provider might struggle to talk themselves out of.

Those old syphillis experiments where patients were told they were getting true treatments for syphilis but instead were given placebo so the researchers could gather data about the progression of untreated syphilis (because no one would knowingly accept letting syphilis slowly kill them just for scientific data), that put some folks in REAL hot water.

So if we are telling patients that we are providing an intervention designed to treat a condition while simultaenously both knowing this intervention is ineffective and witholding knowledge of the functional placebo from the patient so the patient remains unaware of this is... NOT going to look... good... if the patient ever finds out about it and decides to bring it up to a board/lawyer/etc).

I am not trying to scare anybody but knowlingly undertreating or witholding effective treatment from a patient for ANY reason without informing the patient whatsoever that you are doing so... I mean... this will probably NOT look good under the microscope if you catch my drift...