# Question about narcotics and allergies



## Epi-do (Jul 18, 2009)

Recently, I had a run on an elderly lady that had fallen and was having lower back pain.  She appeared to be in significant pain, and I was willing to give her fentanyl.  I asked her about allergies and found out she was allergic to morphine and codiene.  When asked what type of reaction she has, she stated she breaks out in hives and has resp distress.  

Because of her allergy, I was hesitant to give her the fentanyl.  I explained to her that it was in the same drug class as the drugs she was allergic to and I wanted to call the hospital and consult with a doc before giving it to her.  She opted to not have the med, rather than risk having a reaction to it.

Granted, I did have benadryl and epi available to treat an allergic reaction, were she to have one.  I just wasn't comfortable with risking that without talking to a doc first.  Since the patient opted to not have the pain med, I never did call and talk to the doc though.  

I wanted to ask about it when we got to the ER, but they were super busy so I didn't get a chance to talk with any of the docs.  My question is, what would others have done?  Would you have given the fentanyl?  Would you have contacted med control first?  I guess I am just looking for confirmation that I was thinking along the right path when thinking I should check with a doc first, given her other allergies.


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## emtbill (Jul 18, 2009)

Fentanyl is an opiod, and works on the same opiod receptors in the brain that morphine and codeine do. However, it is a fully synthetic opiod made from constituent parts whereas morphine and codeine are found naturally in the opium poppy. There are also semisynthetic opiods like heroin, which is an esterfied molecule of morphine. Anyway, the point is that fentanyl is a different type of drug than morphine and codeine, and your patient may have tolerated it better since it would have different metabolites than other opiods, which may have caused the reaction. Personally I would not have given the drug, partly because she's not going to die of back pain, and also because I don't have the luxury of giving narcotics here on standing orders.


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## rescue99 (Jul 19, 2009)

I'd probably hold off on the meds and place a blanket roll under the patient's knees.


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## Ridryder911 (Jul 19, 2009)

I would had held off as well. Synthetic or not, as a close generation of medication I rather not risk it unless I could closely monitor and have time to be prepared to treat an adverse reaction. There is nothing like treating a reaction, especially after the patient informed you she could be allergic to the medication. Use another or as you did withhold for better options. 

R/r 911


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## Smash (Jul 19, 2009)

As mentioned, fentanyl is structurally different from morphine, as are it's metabolites and it is highly unlikely that it will cause a reaction just because morphine or codeine do.  There is nothing wrong with checking with the doc, however I would have gone ahead and treated the patient (with her consent obviously, although I would have made sure she understood that there was very little chance of a reaction occuring)

I have to say though that I am alarmed that people will withhold pain relief because 'it's not going to kill them' or would just go with a bit of a old blanket roll and you'll be ok dear. :unsure:

Very little that we do in the pre-hospital arena has as great an impact on a patient than providing adequate pain relief.  It is an absolute imperative that we treat patients humanely and appropriately.  Pain doesn't just happen when we have a big car smash or catch fire or have an MI and we should actively and aggressively persue analgesia in all patients regardless of the cause of their.  

Acute pain when left untreated leads to many serious, ongoing systemic problems and greatly increase the risk of developing chronic pain disorders.  Hence the aggressive management of pain both pre and post-op and the specialization of anesthetics into pain management.

Elderly patients (and the young) are at significantly greater risk of oligoanalgesia due to issues in the perception and reporting of pain.  It doesn't mean they don't feel it, just that they don't complain of it.

It is widely recognised that pain relief in acute care (both in the ER and in the ambulance) is something that is often neglected.  Progressive services now include reductions in pain scores as an important key performance indicator for their service.  All paramedics should be aware of and able to use pain rating scales to ensure that they are appropriately assessing and treating pain of any cause in any patient including the young, the old, the insane, anyone.  

Back pain, leg pain, abdo pain, whatever; it doesn't matter what causes the pain, what matters is that we make it go away.


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## emtbill (Jul 19, 2009)

Smash said:


> I have to say though that I am alarmed that people will withhold pain relief because 'it's not going to kill them' or would just go with a bit of a old blanket roll and you'll be ok dear. :unsure:
> 
> Very little that we do in the pre-hospital arena has as great an impact on a patient than providing adequate pain relief.  It is an absolute imperative that we treat patients humanely and appropriately.  Pain doesn't just happen when we have a big car smash or catch fire or have an MI and we should actively and aggressively persue analgesia in all patients regardless of the cause of their.
> 
> Back pain, leg pain, abdo pain, whatever; it doesn't matter what causes the pain, what matters is that we make it go away.



Agreed, just remember that all systems are different. 'Round here I carry morphine, midazolam and diazepam, and morphine is an online order. I won't hesitate to call for a STEMI patient or an isolated long bone injury, but I can't go off trying to give my patient a narcotic every time grandma falls down. If I called for narcotic orders every time I had a patient in pain I would soon be viewed as "that guy", and no one would take me seriously. Also, while you don't have to be an orthopedist to see a patient has a compound fracture, I think some complaints deserve an M.D. level assessment before analgesics are given. 

Now if I had some N2O, or toradol, that would make life a lot easier.


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## Smash (Jul 19, 2009)

emtbill said:


> Agreed, just remember that all systems are different. 'Round here I carry morphine, midazolam and diazepam, and morphine is an online order. I won't hesitate to call for a STEMI patient or an isolated long bone injury, but I can't go off trying to give my patient a narcotic every time grandma falls down. If I called for narcotic orders every time I had a patient in pain I would soon be viewed as "that guy", and no one would take me seriously. Also, while you don't have to be an orthopedist to see a patient has a compound fracture, I think some complaints deserve an M.D. level assessment before analgesics are given.
> 
> Now if I had some N2O, or toradol, that would make life a lot easier.



So pain is only painful if you have broken a long bone or are having a STEMI?  If it was your grandma who fell down, injuring her back, fracturing her NOF or busting her pubic rami, would you A) want her to be in pain or B) not want her to be in pain?

What exactly is "that guy"?  The guy who cares that his patients recieve optimal treatment?  Or the guy whose ego and reputation come first?

Which complaints 'deserve' to have no pain relief?  Abdo pain?  Back pain?  Fractures?  

In what way does the patient benefit by being in pain before the doctor sees them?

I guess I'm lucky in a way.  If I leave a patient at hospital with inadequate analgesia the Drs and the service will be asking me why I didn't bother treating them, I'll get written up and possibly lose my authority to practice.  It's like not giving ASA to chest pains; utterly unthinkable!  Fine by me, it means patients will get what they need.


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## vquintessence (Jul 19, 2009)

Smash said:


> So pain is only painful if you have broken a long bone or are having a STEMI?  If it was your grandma who fell down, injuring her back, fracturing her NOF or busting her pubic rami, would you A) want her to be in pain or B) not want her to be in pain?
> 
> What exactly is "that guy"?  The guy who cares that his patients recieve optimal treatment?  Or the guy whose ego and reputation come first?
> 
> ...



I can totally see what Bill was eluding to as "that guy".  It's an inappropriate stigma when you administer meds rationally and appropriately, but I've been with many services whom carry that overall attitude.  Perhaps not at the levels of management or medical authority (pssst billing too...), but it is prevalent.

Smash, I'm envious of your systems unwillingness to accept the "that guy" mentality!


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## medic417 (Jul 19, 2009)

If the medical director does not trust his people are educated enough to determine proper use of medication he should not allow them to work under his license.  By requiring contact of medical control you delay care and you actually cause people to suffer because the medic is ashamed to make the call as they don't want to be "that guy".  If you choose to work in a mother may I system don't make a patient suffer because of your pride, make the call.


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## ResTech (Jul 19, 2009)

I have both observed and read that many provider are way to conservative with giving their patients analgesia in the field. Should ALS be more aggressive with pain management? I think so.


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## Sasha (Jul 19, 2009)

> I think some complaints deserve an M.D. level assessment before analgesics are given.



A good MD should be able to perform his assesment with or without the patient in pain, your patient should not be left in pain! Epi withheld drugs because of possible allergic reaction, which was the right course of action. No need to put the patient in anaphylaxis on top of a fracture.


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## medic417 (Jul 19, 2009)

Sasha said:


> A good MD should be able to perform his assesment with or without the patient in pain, your patient should not be left in pain! Epi withheld drugs because of possible allergic reaction, which was the right course of action. No need to put the patient in anaphylaxis on top of a fracture.



Why not?  Think about it he could practice his advance airway skills possibly,h34r:


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## Sasha (Jul 19, 2009)

medic417 said:


> Why not?  Think about it he could practice his advance airway skills possibly,h34r:



I hope you are not mocking epi, she's great and very caring.


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## medic417 (Jul 19, 2009)

Sasha said:


> I hope you are not mocking epi, she's great and very caring.



Note the smiley.   Was being sarcastic, never actually cause patient to suffer so you can play.  

Yes EPI did right.  Never harm your patient.  Epi explained the risks and patient agreed to wait.  Very good way to handle situation.  Too many fail to even consider the patients feelings in regards to risks.  So yes I applaud EPI for communicating with patient and not harming patient.


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## ResTech (Jul 19, 2009)

> A good MD should be able to perform his assesment with or without the patient in pain



I agree... the old adage of don't provide analgesia until evaluation by a physician is no longer real applicable. This used to be more of the case a long time ago where physicians had to rely solely on physical exam findings to make a more accurate diagnosis without the advantage of todays technology.  

Today, with the universal availability of CT Scans and MRI, the physician can see inside and see whats going on. The current literature advocates that even for abdominal pain, patients should be given pain relief in the field and providers should start being more aggressive in relieving their patients pain prior to ED arrival.


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## Epi-do (Jul 19, 2009)

I am glad to see that others would have with held analgesics for this particular patient.  We are very fortunate that are medical director has been pretty free with our protocols for pain relief, compared to other services around us.  We can give up to a total of 300 mcg of fentanyl before having to call for orders for additional meds.   We are allowed to give adults 50-100 mcg every 3-5 minutes, so I have rarely had to call for orders for additional meds due to short transport times.

My only wish is that we also carried some sort of non-narcotic analgesic for situations such as this.  This particular patient rated her pain 4/10, however she would grimace and guard every time she tried to move.  She was moving very cautiously and slowly as well, being insistant on trying to move herself rather than having us do it.  We did help her to her feet and then used a stair chair to get her to our stretcher.  

I have been teased from time to time for being "that" provider when it comes to pain management, however, if it makes my patient more comfortable and my job to care for them easier as a result, I don't really care.


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## emtbill (Jul 19, 2009)

Like Epi said, her medical director is a little more liberal with allowing them to give pain meds. I'm not saying that patients complaining of pain don't deserve prehospital analgesics, but I have to be more judicious with who gets them. I really need objective evidence before I consider doing it. I guess that's a downfall of where I work. A lot of services around us don't even carry controlled substances, so we're fortunate to have what we do. There's a lot of red tape every time I open the narcotic box (they're kept seperate from the other drugs)...it's an online order, there's a card in the box accounting for every vial of drug that has to be filled out, signed and witnessed by the nurse and MD when you waste the rest of the med in the sink at the hospital, then I have to call my captain to get into the safe and restock the box. What this boils down to is that there's so much accountability for the meds that only the sickest patients get them. The patient who complains of back pain over the past 4 days but waits until today to call me then walks into my ambulance can wait the 7 minutes it takes to get to the hospital for relief.


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## medic417 (Jul 19, 2009)

emtbill said:


> What this boils down to is that there's so much accountability for the meds that only the sickest patients get them.




So because it makes you do more work you will make a patient suffer?  That is just wrong and non professional.  

All of us have lots of extra documentation when using narcotics, or if not at some point it will bite you in the rear.


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## emtbill (Jul 19, 2009)

It's not me, it's the system. I don't mind the extra work but I wouldn't get orders for lower back pain after a fall. I can only do what the MD will allow me to do.


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## rescue99 (Jul 19, 2009)

A good many areas allow for pain meds in the field pre-radio. No sense in a patient being in pain when we can often do something. In the case of this lady, she has a history with meds. Barring a long ambulance transport, waiting...or maybe Toradol seems most prudent.


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## mycrofft (Jul 19, 2009)

*Follow your protocols. But words I never want to hear (but have) are:*

"Well, we can go ahead, we have epi and benadryl on hand".
That's up there with "I can throw my kid brother off the roof, I have a traction splint in the car".


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## SoCal (Jul 20, 2009)

mycrofft said:


> "Well, we can go ahead, we have epi and benadryl on hand".
> That's up there with "I can throw my kid brother off the roof, I have a traction splint in the car".



I disagree completely, this is taking the situation and rationalizing it. This is thinking ahead, and ultimately Epi did the right thing, however you do have many tools in your box.


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## Sasha (Jul 20, 2009)

SoCal said:


> I disagree completely, this is taking the situation and rationalizing it



There is no guarantee that epi will stop the reaction. You would be putting the patient in a potentially life ending situation with no promise that you can reverse the effects.


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## SoCal (Jul 20, 2009)

Sasha said:


> There is no guarantee that epi will stop the reaction. You would be putting the patient in a potentially life ending situation with no promise that you can reverse the effects.



I agree with you, and like i said Epi did the correct thing, however, thinking about what all you have to use in that "in case" scenario will keep you on your toes...


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## daedalus (Jul 20, 2009)

From what i have seen epi post in my time here, she is a thoughtful and concise paramedic. I think she cares about her profession and patients. I would trust her with my family gladly over some the the sorry excuses out here in socal. I think she has done the right thing, and there is no need to lecture her about the importance of pain control. It seems to me that Epi would if possible always lean on the side of controlling pain.


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## Smash (Jul 20, 2009)

I can't imagine that anyone would actually think that having epinephrine and benadryl on hand would actually justify giving a contra-indicated treatment and re-reading the original post I do not think that this is how it was meant.  It seems to me that she was considering possible outcomes, what the worst case scenario would be and how she would manage it if she elected to give the fentanyl.

I have not really read any of Epi-do's previous posts being new to this board, and I disagree with Epi's decision not to give the pain relief as there is no reason for the patient to have a reaction to fentanyl because they have had a reaction to morphine in the past (they _may_ have a reaction to fentanyl, but this would be entirely coincidental)

However, that said it is obvious that this was done with the best interests of the patient in mind given the situation and understanding of the pharmacology, and she was clearly acting as an advocate for the patient and seeking to ensure no further harm came.

Further to this, the fact that she is asking opinions of other providers from all over the world suggests that she is a self-reflective practitioner seeking to improve her performance and this is exactly the type of person we need in EMS.


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## SoCal (Jul 20, 2009)

Smash said:


> I can't imagine that anyone would actually think that having epinephrine and benadryl on hand would actually justify giving a contra-indicated treatment and re-reading the original post I do not think that this is how it was meant.  It seems to me that she was considering possible outcomes, what the worst case scenario would be and how she would manage it if she elected to give the fentanyl.
> 
> I have not really read any of Epi-do's previous posts being new to this board, and I disagree with Epi's decision not to give the pain relief as there is no reason for the patient to have a reaction to fentanyl because they have had a reaction to morphine in the past (they _may_ have a reaction to fentanyl, but this would be entirely coincidental)
> 
> ...



Thanks for posting that, that is exactly what I was trying to say.


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## mycrofft (Jul 21, 2009)

*EPi-do's post was great. I would never suspect her of the "we got epi/benadryl" bit .*

 I have no inkling nor do I imply that Ms Epi would do something like that.

But my generic statement stands. I have heard parameds, nurses, and even MD's say that and sometimes act on it.

Witholding a pain medication because you honestly suspect a likelihood of anaphylaxis is ethical, thougthful and legal. It is right. Intentionally administering what amounts to a poison (high likelihood of anaphylactoid reaction in a particular pt) because you have the putative antitdote on hand is not only ethically unsound, but illegal and a felony to boot. "House MD" not withstanding, it is wrong.


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## rescue99 (Jul 21, 2009)

In certain situations where reversal of S/S of an allergic reaction is necessary, you bet hospitals do. I can say for absolute fact it's done Mycrofft. It's been done to me on at least 3 separate occasions. I get benadryl and zantac as a precaution anytime I'm given any anesthetic for example and before any contrast. 

In the case of the poster of this thread, she did exactly what she should have done. In a more life threatening situation advice is but a radio call away. That's what Med Control is for! We have advice right at our finger tips, always.


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## medic417 (Jul 21, 2009)

rescue99 said:


> In a more life threatening situation advice is but a radio call away. That's what Med Control is for! We have advice right at our finger tips, always.



Wow that must be nice.  Here you are in communication dead zone much of the time.  Even Satellite phone is not reliable.


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## rescue99 (Jul 21, 2009)

Bummer....and this system would remain BLS until the communications issues could be resolved if communications were that poor. If education requirements don't step up to the plate then restrictions have to be in place. 

There are some very, very rural areas where communication is risky or impossible but, for the most part this should not happen. Portables, 900's, dispatch, land line and a cell. If none of these work and ya don't have the knowledge, skills or ability to make some decisions......revert back to basic. Do what you know.


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## redcrossemt (Jul 22, 2009)

rescue99 said:


> If none of these work and ya don't have the knowledge, skills or ability to make some decisions......revert back to basic. Do what you know.



Shouldn't you have the knowledge, skills, and ability to make decisions regarding every drug and procedure you are trained and equipped to perform?

I am in a system where, thank heavens, we can give narcotics pre-radio. However, dopamine is post-radio for us. Does that mean that if I can't contact med control, I shouldn't give dopamine?

The answer is absolutely not. In the case of radio communications failure, we are trusted to continue on in the protocols. If you are a paramedic, you can not rely upon medical control - you must have the knowledge and skills to perform at the ALS level.


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## rescue99 (Jul 22, 2009)

by "ability" I am referring to not being able to for whatever reason...protocol or otherwise.


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## Ditchmedic (Jul 23, 2009)

*Questions about narcs and allergies*

If they hurt, fix it.  If you are not sure, call Med control, that's what they are there for.


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## Melclin (Jul 23, 2009)

Fentanyl is commonly recommended and used where pts have a morphine allergy. A true allergy to morphine is rare and anaphylaxis is rarer still. Most people with "allergies" have some kind of sensitivity issues or have actually suffered from the histamine release caused by opiates (which can causes varrying degrees of similar, but not as severe, reactions to anaphylaxis), but of course you have to play it on the safe side if they say they have a morphine allergy. Our service carries fentanyl for just such a purpose (also RSI for the big boys, and a general alternative to morphine at the digression of the medic).

As smash says, being as it is that it's an entirely different substance to Morphine, I can't see what reason you would have to think that a morphine allergy would be a problem when administering fentanyl. 

Other than an actual anaphylactic response (as far as I can tell, its debatable whether or not true morphine allergies exist in the same sense as grass or peanut), it is possible to have something called and anaphylactoid (I think) response which is not IgE mediated and does not involve the anaphylactic cascade. It can, however, appear very similar though it is not nearly as serious. It is caused by the release of histamine which is caused by the presence of the opioid. Different opioids have different abilities to liberate histamine. Fentanyl, like other synthetic opioids, have a very low ability to release histamine. As such, fentanyl is far less likely to cause any kind of allergic response.   

*If you are taking on the responsibility of administering a drug, I feel you should know what it's doing to the pt, to the best of your ability (fentanyl is not well understood). This is a great, brief little article that explains it all pretty well:*http://depts.washington.edu/druginfo/DTT/2006_Vol35_Files/V35N4.pdf


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