Fentanyl vs Morphine

[stcommodore]

Hey, I'm trying to get my service to replace morphine with fentanyl. We won't carry both and I feel fentanyl is superior. I need to know how much each costs and make this a dollar and cents argument.

[spenac]

Hey, I'm trying to get my service to replace morphine with fentanyl. We won't carry both and I feel fentanyl is superior. I need to know how much each costs and make this a dollar and cents argument.

Bad choice not to carry both. Morphine is cheaper but neither is expensive. You need to look at the actual benefits to patients and you will find it is best to have both.

[paramedicmike]

Perhaps you should make this more than just a dollars and cents argument. While not unimportant, efficacy and benefits are what's going to matter. There's plenty of research out there supporting the use of Fentanyl. Start gathering that and you can start preparing your comprehensive literature review presentation on the benefit of one over the other or even... <gasp>... carrying both!

Then, once you have your presentation on the evidence based medicine supporting the use of both medications, you can throw in the dollars and cents argument. Be sure to include the potential medical-legal argument as well. "Appropriate patient care" and "medico-legal issues" are always key buzzwords to grab people's attention.

Good luck. Let us know how you do.

[fiznat]

We just got fentanyl into our kits (in addition to morphine), and I actually used it today for the first time. 150 mcg for a guy with back pain from shoveling. With that amount of medication he went from unable to move to getting up out of his chair and taking a few steps to the stretcher. I understand that is about the equivalent of 15 mg of morphine, which seems about right. The difference was there was no hypotension, no nausea, no dirty side effects. The onset was quicker but seemed less overwhelming and uncomfortable for the patient. This was only my first time using it, and I know this isn't the kind of answer the OP is looking for, but I'm liking it so far. I've found morphine to be a very unpredictable drug and I never knew exactly how my patient would react with it. I'm hoping fentanyl proves to be a good substitute.

[Emtpbill]

Only thing with fentanyl is it has a short half life. If u have a long transport time you may have to redose. Other than than fentanyl is awesome for pain mgmt. 150 mcg is a good dose.

[Bieber]

We just got fentanyl into our kits (in addition to morphine), and I actually used it today for the first time. 150 mcg for a guy with back pain from shoveling. With that amount of medication he went from unable to move to getting up out of his chair and taking a few steps to the stretcher. I understand that is about the equivalent of 15 mg of morphine, which seems about right. The difference was there was no hypotension, no nausea, no dirty side effects. The onset was quicker but seemed less overwhelming and uncomfortable for the patient. This was only my first time using it, and I know this isn't the kind of answer the OP is looking for, but I'm liking it so far. I've found morphine to be a very unpredictable drug and I never knew exactly how my patient would react with it. I'm hoping fentanyl proves to be a good substitute.

We use fentanyl around here and to be honest it's been fairly rare that my patients have ever reported much (if any) relief from it. Our standing orders are for 1 mcg/kg followed by a second 1mcg/kg if no relief after I think five minutes. I'm not sure if it has to do with our fairly short (around 15 min) transport times or if perhaps the dose is too small. I've never given more than a hundred mics to anyone before, and I've never redosed anyone either. How long did it take your patient to start getting some relief?

Also, do you usually give pain management on scene? The only time I've ever started an IV on anyone outside of the truck has been on code blues, and I can't imagine doing much on scene unless it was like a diabetic emergency or an arrhythmia type deal. At least from the paramedics I've worked with so far and from my experience with my preceptors, everyone around here is very much "load and go" with very little scene time. I assume that's probably because our times are what's looked at when it comes to performance evaluations, and nobody wants to spend time on scene to get a line or push any meds unless they're critical. Do you guys have that kind of restriction or are you guys fairly free to take as much time as you need? Also, out of curiosity, do you usually get your IVs on scene or in the truck?

[DwayneEMTP]

I've found that though Fentanyl doesn't have the hemodynamic effects that scare everyone so bad with Morphine that it's also a wuss where significant pain is concerned. At the doses we were allowed to give it, 100mcg with an addl 100mcgs per med control (This was the only service I worked that had it) that it just didn't have the muscle I wanted for most really good injuries.

Plus the hospital will dose them with morphine as soon as you get to the ER anyway as the effective life of the Fentanyl is nearly useless for them and the time that they need effective pain management to do their evals and treatments.

It's been my experience that the number one reason that people like Fentanyl is that they're afraid of Morphine, and though I've pushed gallons of it, I've only seen the severe hemodynamic effects less than a handful of times...and of those times simply laying my pt down, or bolusing a little fluid compensated for that without any real drama.

I think the Fentanyl is good for mild to moderate pain at the doses used by most EMS, but you'll be disappointed the first time you use it for a significant injury. Now, when I talk to the old guys that had protocols for a loading dose at 400mcg, I can see that having some value, and others that are allowed to mix Fentanyl and benzos, I can see that too..but stand alone at the 100-200mcg doses...I will always choose MS for hardcore stuff.

But, I almost always push Promethazine prior to MS as the two together seem to give a nice mellow buzz, plus after the Promethazine I often don't need the MS at all.

Dwayne

[fiznat]

Also, do you usually give pain management on scene? .....Also, out of curiosity, do you usually get your IVs on scene or in the truck?

It depends on the call. For this patient I chose to wait on scene, start a line and give the guy some analgesia before we attempted to move him. He didn't have a pressing medical problem other than his pain, and I didn't see a reason to rush to the hospital before making him comfortable. I do this with a lot of back pains, kidney stones, hip injuries, etc etc etc. If the patient isn't unstable, I have no problem taking as long as necessary to make the patient comfortable and pain-free before we start moving.

Usually I am more a "load and go" kind of provider, but if there is something that the patient needs on scene, I'll give it on scene.

[island emt]

We've had fentynal on our trucks now for 4 years replacing Morphine for pain control. Much less side effects and in most people it does a decent job.

HOWEVER

Now on to a personal experience. Last month I slipped on some ice , feet went out from under me, landed full force on my left shoulder.

After laying there for a minute or so I did a head to toe survey and decided everything was in working condition except for my left shoulder and some serious rib pain from driving my elbow into the ribcage. I discovered a lateral dislocation and slowly applied traction to allow it to slide back into semi normal position. After the stars stopped spinning in my eyes , I got up and tucked my forearm into my coat and drove myself to the hospital.

Yeah I know : why didn't I call for an ambulance. By the time they got the call and got to me , I could drive to town and the ER.

Now you want to talk about getting abuse from the ER staff :-} The ambulance guy being the PT.

Finally after dropping my insurance card at registration and walking into the triage cubicle, the nurse looked at me and decided I needed pain relief.

As soon as they could, they got me a room and started an IV, pushed 50 mcg's of fentanyl ;;; 3 minutes go by nothing at all, 50 mcg's more ;;;; still absolutely zero effect on pain that's now at a solid 8/10.

I'm not the squeamish type and have a very high pain tolerance, but 100 mic's wasn't cutting it. Rather increasing the dose the ER doc decided to go with 10 mg of morphine and a few minutes later after walking down the hall to get X-rays 2 vicoden PO. The doc , who is a good friend says: What do you mean you reduced it by yourself ?????? I told him it was that or I would have had to wait until I got all the way to the hospital for some relief.

By now I'm getting the pain relief I needed.

Then they made me call my wife who works upstairs as an RN on the surgical floor to come drive me home, guess i was getting a little goofy by the time the vicoden kicked in.

What I'm trying to pass on here is that while Fentanyl is a good drug for pain relief in many Patients, It doesn't work for all. It's another tool in the box.

[JakeEMTP]

What I'm trying to pass on here is that while Fentanyl is a good drug for pain relief in many Patients, It doesn't work for all. It's another tool in the box.

Exactly. You really need to have both medications available to you. I've knocked people out with 50mcg of Fentanyl. Others 50mcg won't touch and require require a higher dose. I prefer to administer MSO4 to my Cardiac pt.'s due to the vasodilation of the drug, except for most Right-sided events.

Fentanyl IMHO is a great tool. As a provider though, you need to evaluate the pt. and decide what they require. To have the option of Fentanyl or MSO4 is paramount and you SHOULD carry both.