Oral pain med alternative

[laderalis]

We have a resident that often refuses anything oral. She has some pain in her hips/legs that was are treating with Lortab elixir. We cannot use a fentanyl patch because of an allergy. Is there another non-PO pain med option out there? She has some mild anxiety occasionally so I was thinking maybe some Ativan gel might help. Any other ideas?

[toomuchbaloney]

You don't give us too much info about the pain.

Subcutaneous infusion?

[cayenne06, MSN, CNM]

is she allergic to patch adhesive, or fentanyl itself?

[chopwood carrywater]

If it's neuropathic you could try gabapentin; if she won't take itin pill form you could try sprinkling it on something she will take.

Lidoderm patches might work if the adhesive is not an issue.

Warm compress or heating pad might work - careful about not getting skin too hot.

Massage might help.

Any possibility that she would accept medication per rectum?

Like TMB said, SQ - using an infusion port (have to change it q 5 days) would be a good alternative.

Why does she not take meds PO? Taste? N/V? End of life issues?

[laderalis]

We are not entirely sure where the pain is because she is non-verbal and has dementia. From her body language it appears to be in her hip/leg. She will not take much by mouth. I'm guessing either due to the dementia or because of the taste. One time i dissolved a sugar packet in her 5ml of Lortab and that went a little better. All the nurses are tired of coming at her with meds that she hates taking, so we were trying to find a non-PO alternative.

She is very frail so I don't know how well a subQ infusion would work.

She has an allergy to some oral narcotics, I can't remember which one specifically. It's not an adhesive allergy. We also don't know what exactly her allergic reaction was. It could have just been an adverse side effect and not a true allergy.

She is taking Lortab 5ml TID now, so I don't know how much a lidoderm patch would help?

I hadn't thought about per rectum, I'll ask our hospice nurse about that.

[BeachsideRN, ASN]

Some pharmacies can compound pain creams. They often have lido, gabapentin, amitriptyline, etc in them and can be customized per patient needs

[scottaprn]

keylimesqueez is dead on with the compounding creams available. I write them all of the time in ortho and they are very flexible with what is included etc. There are many companies that make them nationally. I don't want to plug a company on the message board but if you pm me I can send you the names of reputable compounding pharmacies I have used

[motherof3sons]

Many oral meds can be given rectally(with an order of course), but there are morphine suppositories and I am sure many other meds in that form.

[heron, ASN, RN]

Also, sq infusions are very well tolerated by the frail elderly, if you're careful about volume. They can be placed just about anywhere, including the back, thigh and abdomen. The commercially available sq infusion sets are very comfortable, almost un-noticeable. I've used them for both continuous and intermittent infusions - just need to flush with a bit of saline.

Rectal admin. sounds the most promising, though. I've given po tabs per rectum - just have to be careful to place them right up on the bowel wall, not in a mass of stool

[annie.rn]

I have also used the rectal route of administration for oral medications with good efficacy. There are some things to consider when doing this, however. Here is a very good article explaining how to properly give oral medications rectally:

http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_257.htm

You need to be careful not to administer too high in the rectal vault or the absorption of the medication may be decreased by the first pass metabolism of the liver.

For what it's worth, I love the website that this link takes you to. Lots of "Fast Facts" for palliative care nursing. Always something fascinating to learn.