Fentanyl; Why even carry Morphine?

[NYMedic828]

Here in NYC as I've stated in the past we RARELY utilize pain management but we do carry fentanyl and morphine Carpu-jets.

If i suggested IN fentanyl for a ped injury to most partners, they would stare me down with a wtf look.

Our fentanyl stock almost never changes unless something expires. Same goes for morphine.

But anyway, what's the purpose of even having morphine when fentanyl doesn't cause as many adverse reactions?

To my understanding, fentanyl binds more selectively reducing side effects prevalent with morphine and it doesn't cause the histomine response that morphine does.

Fentantly is discretionary here for anything but a hypotensive patient needing pain management

Is the reason out of fear that we will give too much and not be able to reverse it as easily as morphine?

I just don't understand why we even bother with morphine, fent just seems all around superior?

 

[rogersam5]

I don't either, in Maine we don't carry morphine unless there is a recognized drug shortage of fentanyl and all the hospital pharmacy can give us is morphine

 

[NYMedic828]

Truthfully I think one main reason is they don't trust our providers, and with good reason. If I was the medical director I wouldn't.

Most people here in NYC/ LI if you asked them what morphine/fent does all they could tell you is they reduce pain because they are opiate agonist. All they know "fentanyl is stronger and omg dangerous!"

 

[Veneficus]

Here in NYC as I've stated in the past we RARELY utilize pain management but we do carry fentanyl and morphine Carpu-jets.

If i suggested IN fentanyl for a ped injury to most partners, they would stare me down with a wtf look.

Our fentanyl stock almost never changes unless something expires. Same goes for morphine.

But anyway, what's the purpose of even having morphine when fentanyl doesn't cause as many adverse reactions?

To my understanding, fentanyl binds more selectively reducing side effects prevalent with morphine and it doesn't cause the histomine response that morphine does.

Fentantly is discretionary here for anything but a hypotensive patient needing pain management

Is the reason out of fear that we will give too much and not be able to reverse it as easily as morphine?

I just don't understand why we even bother with morphine, fent just seems all around superior?

There is no such thing as a "superior" drug. Only a different one.

There are pros and cons to both.

It depends on things like whether or not the side effects are desired. I use promethazine rather frequently over ondosterone on purpose. I want the patient sedated and sleepy. (side effects) The fact that it helps reduce n/v, and is a 1st generation antihistamine (just like benadryl) is a bonus in my book.

Plus since it is a sedative, you don't have to add a benzo to your mix. 2 drugs instead of 3.

morphine also supposedly lasts longer. Which is good if the patient is going to sit in the ED for a while. Not to mention if you have a pt with GI discomfort and diarrhea, the fact that it relieves pain and causes constipation doesn't go amiss.

Provider comfort actually has a fair role in the mix as well. It is just like backup airway adjuncts. It is better to be great with 1 or 2 than familiar with a dozen.

Calling fent "better" is just too over simplistic.

Sounds like what you need is medical direction that calls people on the carpet for not using pain control.

 

[NYMedic828]

I'm not sure if it's an issue with people being fearful of utilizing pain meds or just a matter of complete laziness. My opinion is 9/10, it's the latter.

I have stopped mentioning the idea of it to my partners unless the patient is in massive pain. They always go nahhh well be at the hospital in 5 minutes why bother.

My theory is, why force them to have pain if you have a solution. You want to be considered more than an ambulance driver, then prove it to the patient.

When I'm working in my volunteer department, I'm almost guaranteed to be the sole paramedic available which is much more desirable in my mind. Rarely do I have a partner i actually feel I can truly consult with. I'm a newish medic but that's even more the reason I shouldn't be teaching my teacher...

 

[Anjel]

We carry morphine for cardiac chest pain.

Not pain management, that is what fentanyl is for.

 

[NYMedic828]

We carry morphine for cardiac chest pain.

Not pain management, that is what fentanyl is for.

Is the theory behind this further more prolonged preload/after load reduction in conjunction with NTG, while also providing analgesia?

We had morphine as a medical option for chest pain but it has since been removed and NTG is the sole primary treatment now.

I would think the nausea potential of morphine could make some worse as well if an antiemetic is not also available to you.

 

[Anjel]

Is the theory behind this further more prolonged preload/after load reduction in conjunction with NTG, while also providing analgesia?

We had morphine as a medical option for chest pain but it has since been removed and NTG is the sole primary treatment now.

I would think the nausea potential of morphine could make some worse as well if an antiemetic is not also available to you.

More so reducing oxygen demand and reducing the size of an infarct.

Is what we were taught in class.

And we do have zofran.

 

[NYMedic828]

More so reducing oxygen demand and reducing the size of an infarct.

Is what we were taught in class.

And we do have zofran.

I can't say I have heard of it physically reducing infarct? I guess in theory if you can dilate the vessel that much more, more can fit around the blockage but at that point I would think loading more nitrates would cause far more profound dilation?

If it actually reduced infarct directly I imagine it would be considered first like treatment.

We just got zofran in NYC but in my volly department we only have morphine.

 

[Christopher]

More so reducing oxygen demand and reducing the size of an infarct.

Is what we were taught in class.

I've been entertained by the bulk of textbooks which espouse the theory that morphine is useful in cardiac chest pain, as the literature does not share this outlook. The best you get is, "we should study this and find out if morphine actually does what we think it does."

Gross GJ. Role of opioids in acute and delayed preconditioning. J Mol Cell Cardiol 2003;35(7):709-18.

These results, although preliminary, suggest that opioids may have the potential for treating acute or chronic myocardial ischemia in man.

Welch TD, et al. Modern Management of Acute Myocardial Infarction. Curr Probl Cardiol 2012;37:237-310:

Opioids are not known to influence clinical outcome in AMI.

Worse still, the CRUSADE trial seemed to show that Morphine isn't the best choice in cardiac chest pain as it actually may increase mortality.

 

[nocoderob]

I have stopped mentioning the idea of it to my partners unless the patient is in massive pain. They always go nahhh well be at the hospital in 5 minutes why bother.

My theory is, why force them to have pain if you have a solution.

Never understood that, "Only 5 mins out," nonsense. You wouldn't with hold oxygen since you are only "5 out."

I agree, you can help, so why not? People seem to forget that the pt has to be evaluated and orders given before they recieve pain management at the ED. That is most assuredly going to be much longer than "5 minutes."

 

[fast65]

We carry both fentanyl and morphine, in fact, we just got fentanyl a few months ago to replace butorphanol.

We also are carrying morphine for cardiac chest pain, as well as for part of the CHF treatment line. That being said, I find morphine to be most useful when I do IFT's, as it tends to last longer than fentanyl, requiring less frequent dosing.

For most people, I use fentanyl as a first line for pain management. Most of our transport times are 5-10 minutes, so I'm a fan of the quick onset, and although studies have found no appreciable difference in the efficacy of fentanyl over morphine, in my experience, fentanyl works a little better.

As vene said, each drug has it's pros and cons, and it's difficult to say that one is better than the other.

 

[Christopher]

We also are carrying morphine...for part of the CHF treatment line.

Morphine and CHF doesn't have a good outlook either, starting in the early 2000's its usage has been questioned.

Mosesso VN, et al. Prehospital Therapy for Acute Congestive Heart Failure: State of the Art. Prehosp Emerg Care. 2003;7:13-23. [PubMed]

Its popularity in treating pulmonary edema is due to its vasodilatory and antianxiety effects, although morphine’s vasodilatory effects are transient and the result of histamine release. Recently, concerns have been raised over the use of morphine in treating acute CHF in the ED. A retrospective study of the ED management of APE and intensive care unit (ICU) admissions showed that morphine administered in the ED was associated with significant increases in ICU admissions and the need for endotracheal intubations (ETIs) when compared with sublingual captopril. Additionally, a prospective study of morphine treatment in prehospital APE showed that the drug was minimally effective as single therapy or in combination with nitrates.

More recently the ADHERE trial was fairly damning in its analysis of morphine and CHF:

Peacock WF, et al. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J. 2008;25(4):205-9. [PubMed]

Morphine is associated with increased adverse events in ADHF which includes a greater frequency of mechanical ventilation, prolonged hospitalisation, more ICU admissions and higher mortality.

 

[fast65]

Morphine and CHF doesn't have a good outlook either, starting in the early 2000's its usage has been questioned.

Mosesso VN, et al. Prehospital Therapy for Acute Congestive Heart Failure: State of the Art. Prehosp Emerg Care. 2003;7:13-23. [PubMed]


More recently the ADHERE trial was fairly damning in its analysis of morphine and CHF:

Peacock WF, et al. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J. 2008;25(4):205-9. [PubMed]

I'll take a more in depth look into those studies, thanks!

I haven't personally used it in CHF, but like I said, it's an option in our treatment guidelines. I'll look into it's use a little bit more, and maybe I'll talk to my medical director to see what his thoughts are.

 

[Christopher]

I'll take a more in depth look into those studies, thanks!

I haven't personally used it in CHF, but like I said, it's an option in our treatment guidelines. I'll look into it's use a little bit more, and maybe I'll talk to my medical director to see what his thoughts are.

We got rid of morphine/lasix and added ACE inhibitors for CHF after reviewing the literature. We still carry lasix, but its for prolonged transports or medical control only with pediatric pulmonary edema.

 

[NYMedic828]

We still have morphine for pulmonary edema but not suspected MI.

I don't know anyone who has given it for APE though.

We also have 1-2mg of versed for APE, I assume the reason is as an anxiolytic for that "drowning" feeling...

 

[KellyBracket]

...
Worse still, the CRUSADE trial seemed to show that Morphine isn't the best choice in cardiac chest pain as it actually may increase mortality.

Read the study, and I just can't imagine that the result would stand up in a prospective trial.

I think the key is that is was a NSTEMI population. They're a heterogeneous population, with comorbid problems mixed up with their troponin releases. Probably morphine administration was just a marker for their level of sickness, in a way that wasn't adjusted for in the analysis. As long as you don't give grams of it, morphine one of the safer meds out there.

And yeah, for EMS, I agree that fentanyl should be the standard. Good stuff.

 

[Smash]

Sorry, double post

 

[Smash]

I think Vene covered the question if fentanyl entirely.

For pulmonary edema I think small doses of versed would be a much better idea given the concerns over morphine.
I'm not a fan of the CRUSADE registry, I think it probably unfairly gives morphine a bad rap. Nonetheless I think there are other, possibly better options.

We unfortunately still carry furosemide and are expected to use it. Worse, if we manage to get away without giving in the ED will typically have a spaz and pour 200mg into the poor unsuspecting patient straight away. I wouldn't necessarily like to see furosemide removed entirely, I would just like a bit more discretion (and to have our docs brought up to speed)

 

[Smash]

And while I was double posting Kelly covered why the CRUSADE registry is a bit of a crock. Thanks!