The following response is portions of an individual response provided to Mara in the Ask a Professional area of the Canadian Virtual Hospice website. This is being shared on the bulletin board with Mara's permission.
Thank you for your question about how to give an intramuscular injection (an injection into the muscle) with less pain. Two of the most common ways to give injections are into the muscle or into the fatty tissue (subcutaneous tissue). Your muscle is located under the fatty tissue, so when a person is trying to give an injection into the muscle, you must go through the subcutaneous tissue to reach the muscle.
We have found several web sites that discuss how to properly administer a medication by intramuscular injection. We have included some below that may assist you in the specific technique used to give an intramuscular injection (also known as an "IM injection"):
http://www.ebiocare.com/infocenter/consumer/educationlib/intramuscinject.html
http://www.pkids.org/admim.pdf
http://www.med.rug.nl/pharma/who-cc/ggp/annex4/page06.htm
http://community.healthgate.com/GetContent.asp?siteid=holycross&docid=/dsp/iminjection
This site has some excellent tips of how to minimize pain when injecting a medication, under "Tips for Minimizing Injection Pain". These might be things that you need to consider and may be helpful to you.
Another tip is to use 2 needles when giving a medication. Use one needle to withdraw the medication (morphine) and then keeping the syringe sterile, remove the needle used to withdraw the medication and replace with a clean, unused needle onto the syringe prior to giving the injection. The clean needle may cause less pain, as there is no medication on the needle (which can cause irritation to the tissue when inserting the needle). This is something you might want to try.
You state that you are taking a 45 degree angle when injecting the morphine into the muscle. In fact, when injecting into the muscle a 90 degree angle should be used. There may be a reason as to why your health care team has taught you to use a 45 degree angle, but I would suggest you specifically ask them what angle you should be using to give the intramuscular injection to your husband.
You have been using two sites to inject the morphine. You have used the upper thigh (vastus lateralis) and tried the arm (the deltoid) as well. It is possible to use other sites. It has been documented that the ventrogluteal site (back of the hip) is a very suitable site to deliver intramuscular injections. In order to use this site you will have to be taught by your health care team how to give an intramuscular injection into this site (a person has to landmark appropriately in order to ensure they are injecting into the correct muscle and are not close to any major nerves).
Another suggestion is to rotate where you are injecting the medication. If you keep a chart of which areas you have used, you can develop a method of rotating sites that works well for you and your husband. If one site is used continually it can become very painful and irritated. The pain and lumps might also indicate some sensitivity to the drugs and/or its preservatives. Maybe switching to hydromorphone (another opioid medication) would help.
The following information is geared to health care professionals, but it does have some information that you may want to know about. It contains information about intramuscular injections, such as what muscles to use and a technique called the "Z-track technique" . The informational pamphlet for nurses can be found at:
http://www.breastcancerprofessional.com/contents/public/onc/nursing.pdf
Page 6 describes how to use the Z-track technique, which "traps" the medication in the muscle and it is thought that this technique can decrease the pain experienced with an intramuscular injection. You may want to discuss this technique with your health care team. They should be able to demonstrate how to use the technique, so that you could try this with your husband.
These are some suggestions that hopefully will help your husband to have less pain with his injections of Morphine. The injection of any medication will cause some discomfort in the muscle, as the medication does not the same constitution as muscle. You may never be able to fully alleviate the pain he experiences with intramuscular injections, but some of these suggestions above will hopefully make a difference in decreasing the pain your husband is currently experiencing.
We would like to suggest that it may be possible to change the route by which you give the morphine (or possibly another pain medication). There are other possibilities that we will describe below:
1) Your health care team may want to consider trying another medication that may not be as painful to inject into the muscle (though this may not be certain). This could be another opioid (such as Hydromorphone).
2) The subcutaneous route gives medication into the fatty tissue. It can be given by an injection (which you are already used to preparing). It is also possible to place an indwelling over-the-needle cannula into the subcutaneous tissue. This would mean that you would give your husband a needle into a port that is already inserted into his subcutaneous tissue. This is a route that we commonly use in palliative care.
3) The use of a central line could be considered. A central line gives access to veins by being inserted into the chest wall into a vein. The central line comes out of the skin. This is an option that you would most likely use as a last resort, as a central line requires reasonable maintenance (changing the dressing twice a week as well as other maintenance). There is also the possibility of developing an infection from a central line, and a central line must be inserted in the operating room.
4) In palliative care there is some experience using opioids under the tongue or as a nasal spray for pain. However this has not been extensively used for angina pain (there have been no studies published on this). Nonetheless, it may be worth trying. Your health care team would most likely want to contact a physician with palliative care expertise before trying this route of medication delivery.
Simone Stenekes RN, MN
Clinical Nurse Specialist
Canadian Virtual Hospice
and
Mike Harlos MD, CCFP, FCFP
Palliative Care Physician Consultant
Canadian Virtual Hospice