Fentanyl vs Morphine

[Eydawn]

I'm just barely taking my baby steps into pharmacology (and they won't give me any details yet, the bastids) but to my understanding it would be beneficial to carry both for several reasons.

1: Fentanyl has a short half life, making it effective for use in situations where your physician may need to assess pain as part of their diagnostic process. So, you get to give your patient some pain relief, but have it wear off soon enough for the doc to do what needs done, and then re-dose with Fentanyl or another narc. Also, if your patient is sensitive to narcs, and the Fentanyl snows them, it can wear off quicker making your need to use Narcan or similar less imminent...

2: Isn't morphine more often used in cardiac situations for reducing pre-load? Since Fentanyl doesn't have the same hemodynamic effects, wouldn't that make it fairly useless in cardiac related situations? Or am I off in left field? In any case, you would want to have the morphine available...

3: Fentanyl is less likely to cause a histamine response, no? This could be a good thing.

4: Different patients metabolize drugs at different rates and have different subjective relief... do you really want a patient to come back and state that your standard of practice was lacking because you were being a cost-miser, so they had to endure a transport of XX time in 100/10 pain... you see where this is going? It's all about dodge the lawyer and cover all bases here.

Just my humble thoughts.

Wendy

CO EMT-B

Student Nurse

[Timmy]

I guess a luxury of working in the hospital is we have flexibility as to what analgesia we give to patients.

In the Emergency Department I haven’t seen or used Fentanyl as a first line analgesia. Morphine tends to be our drug of choice in most, if not all situations were patients experience moderate to sever pain. We seem to use Morphine on any array of medical issues whether it be cardiac, trauma or ‘other’ pain related ailments. If were having trouble managing pain with Morphine we tend to add some Codeine or ketorolac tromethamine or perfalgan and if all else fails we can pick up the magic phone and call for an anaesthetics registrar who can wave there magic wand and cure the world of its problems with epidural, regional nerve blockades and all there fancy anaesthetics.

Fentanyl is used quiet a bit in orthopaedic patients, when I’m on surgical ward its quiet common for patients to have a controlled infusion (PCA) of Fentanyl with PRN Morphine or Oxycodone which we strongly encourage patients to ask for. It’s quiet common to have patients who suffer from chronic pain to be on Fentanyl transdermal patches but overall we don’t seem to use Fentanyl as a loading dose or front line medication. Even in kids we seem to Tirade there morphine dose and complement it with inhaled analgesics.

To be honest I really haven’t experienced any adverse reactions with giving patients analgesia (touch wood!) I’ve given morphine to patients until they have slurred speech and can barley talk or open there eyes but are adamant they still have sever pain with no ill effect.

It’s our standard practise to give Metoclopramide before we give any opiod medication. You’d be surprised how many patients state they are ‘allergic’ because they vomited when administered Morphine but when you obtain a thorough history you discover they were never administered an antiemetic and amazingly with 10mg of Metoclopramide they experience no ill effect (miracle workers we are!)

I think analgesia is one of those ‘horses for courses’ topics were everyone seems to have differing opinions based on there experiences. I thinks it’s necessary to have multiple analgesic agents available because everyone has different pain thresholds and metabolism. I’ve seen a fractured leg respond well to something as simple as inhaled methoxyflurane and other patients who you think you’re going to narcatis because you’ve given them so much morphine but there still bellowing and screaming bloody murder, everyone’s different I guess.

[NYCEMS9115]

Tarascon Pharmacopoeia 2011 priced Morphine at $$$$ which is greater than $100 but less than $200. Fentanyl is $$$$$ which is greater than $200 but $$$$$ is the highest notation of cost in the book. Chemotherapy costs for one treatment is $$$$$ and it costs thousands of dollars. So Fentanyl is more expensive & in the Pr-Hospital setting; the service will not carry both; if there's an option. It just makes financial sense. Unfortunately, heathcare must make financial sense for the institutions and patients is foremost than the care. Well at least in America. All the best....

[zippyRN]

Tarascon Pharmacopoeia 2011 priced Morphine at $$$$ which is greater than $100 but less than $200. Fentanyl is $$$$$ which is greater than $200 but $$$$$ is the highest notation of cost in the book. Chemotherapy costs for one treatment is $$$$$ and it costs thousands of dollars. So Fentanyl is more expensive & in the Pr-Hospital setting; the service will not carry both; if there's an option. It just makes financial sense. Unfortunately, heathcare must make financial sense for the institutions and patients is foremost than the care. Well at least in America. All the best....

do you know what the actual price, as in cost to produce, of morphine is ?

well under a dollar ( US, Loonie or Upside Down it doesn't matter) for a 10 mg ampoule ...

Edited February 5, 2011 by zippyRN

[NYCEMS9115]

Well Tarascon goes with the $ notation for cost of per month or per course. It may cost nothing to make but the cost of the little hands in the sweatshops in Malaysia to make you Nike Jordans are pennies but you paid $100+ for them. That's capitalism for you.

See Tarascon Pocket Pharmacopoeia 2011 Classic Shirt-Pocket Edition 25th Edition, ISSN 1945-9076, ISBN 977-0-7637-9305-0. Go to pages viii, 7 and 8... Email them at info@tarascon.com. I'm not making it up.

[NYCEMS9115]

I'm just rationalizing what institutions, like Ambulance Services, will option for: the cheapest route. I don't blame them; if they don't have to do it; then they won't. Its about the dollar. My Private Service has Capnography because NYS mandated it; if they didn't we would be still using the Colored C02 Detector. If I was the owners, I would rather pay for CO2 Dectors than Capnography; its so much cheaper. Its not like the Protocol warrants ET Intubation; it states that if effective ventilations can be given with a BVM and a basic airway adjunct; intubation can be differed.

In a discussion, I look at all sides: my side, your side, his side, her side, & their side. Right now I'm looking at their side. If I would look at stcommodore's side; I would look for the better one of the two & it would be for Fentanyl. But that would be too easy... All the best...

[spenac]

http://www.buyemp.com/category/Narcotics-Class-II.html

Not enough cost difference to justify one over the other. They are cheap. In fact when stolen (if it were not for the control status)cost value would be misdemeanor.

[DwayneEMTP]

I'm just rationalizing what institutions, like Ambulance Services, will option for: the cheapest route. I don't blame them; if they don't have to do it; then they won't. Its about the dollar. My Private Service has Capnography because NYS mandated it; if they didn't we would be still using the Colored C02 Detector...

At my last service, a private service, we has capnography, CPAP, glidescopes (just recently), Fentanyl and Morpine, non but the Morphine mandated by the state. How does this fit into your theory?

Dwayne

[Matt W]

Not gonna get into the discusion of which is better because thats not what the original questions asked and you'll never get a solid answer on that, they are different drugs and both have their pros and cons. Cost though according to our pharmacy that we replace our drugs at is as follow:

Fentanyl Inj 100mcg/2ml - $0.28

Mophine 2mg/ml carpuject - $0.89

Mophine 4mg/ml carpuject - $0.92

Mophine 10mg/ml carpuject - $0.91

Hope this helps. Let us know the outcome.

[NYCEMS9115]

If its mandated than we must carry and comply. If not, then the option to not have will be the option. I'm not saying I would; I'm not the owner. I was looking it at the owner's side. As for being a Paramedic; I want more training and all the skills possible but I do have to look at it financially. I don't work on the road. I would like to know the site which shows the price for Morphine & Fentanyl. Thanks...