Pain expert Dr. Scott Fishman answers questions about pain medication:

Q: What are the alternatives to shots and pills for taking pain medication?

A: Pharmaceutical companies have developed a number of alternatives to shots and pills. The hypodermic needle and hollow syringe were invented around 1850. Since then, doctors have been looking for other ways to deliver medication.

Many people cannot tolerate shots, and doctors often want to get medication into the patient's central nervous system more quickly than a shot permits. Today, the alternatives for delivering pain relievers include patches that pass medication through the skin, nasal sprays, inhalers, and quick-dissolving wafers.

Patches are used to deliver opioids, particularly fentanyl (brand name Duragesic). Fentanyl, a synthetic opioid that is 72 times to 125 times stronger than morphine, is one of the most fat soluble of narcotics, so it quickly speeds through the skin and into the brain. Fentanyl delivered through a patch offers a steady, sustained infusion of the drug.

The patch is composed of multiple layers of material that keep it glued to the skin and full of enough time-release medication to last for days. The drug needs about twelve hours before it reaches its optimum dose and usually needs to be changed every three days. Patches are limited however. They cannot be used for drugs that do not readily penetrate the skin, such as large-molecule, genetically engineered drugs.

A lollipop-style applicator recently has been developed and also is used to deliver opioids like fentanyl. The product is called Actiq and is a sweetened lozenge on a stick that is laced with high-powered fentanyl. This is an exceptionally clever and speedy delivery system to the blood stream.

When rubbed against the inside of the cheek (it is never directly sucked on), the opioid travels through mucosa tissue on the inner walls of the mouth. The unit has only to be rubbed on the inside of the cheek to rush opioids to the brain. It travels faster than any pill and about as fast as an intravenous injection of morphine. Patients say they feel relief within five minutes of putting the unit in their mouth.

The nose is one of the most direct routes to the brain. Nasal sprays of flu medication and other conditions are already available, and sprays for other medications are sure to follow. For years, inhalers have been a godsend for asthma suffers, and now this method for delivering drugs is spreading to other medications, including pain relievers.

Inhaling a substance sends its molecules deep into the lungs for quick absorption into the bloodstream. Inhalers are being developed and tested to deliver fast-acting morphine for breakthrough pain at rates that are just as fast as any direct intravenous shot can deliver.

The advantages of a quick-dissolving wafer include the fact that they are easy to carry and require no water or gadgets to work. Makers of the migraine medication rizatriptan (Maxalt) offer it in a wafer that dissolves on the tongue within seconds.

Needleless injectors are also on the horizon. Resembling fat pens, these devices use compressed helium to shoot a dense cloud of microscopic drug particles into the skin at speeds of Mach 3. While early versions of these drug guns caused bruising and pain, the models now being refined are virtually painless.

Immediate uses of these injectors include "shots" to deliver local anesthesia before a painful procedure. A variation of this method currently in development is a device that uses an electric charge to push a drug painlessly through the skin and into the bloodstream.